Form 150-105-003 - Cigarette Tax Bond
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1Clear Form
For department use only
Date received
OREGON
BIN
License number
CIGARETTE TAX
BOND
Bond number
FEIN
_____________________________________________________________________________________________ ,
(Name of principal (licensed distributor))
of __________________________________________________________________________________ , as principal,
Address of principal
and ___________________________________________________________________________________________ ,
(Name of surety)
a corporation acting as an authorized surety insurer under Chapter 742 of the Oregon Revised Statutes, with a business
at __________________________________________________________________________________ , as surety, owe
(Address of surety)
the State of Oregon, ________________________________ Dollars ($ ____________________), for which payment
principal and surety bind ourselves and our legal representatives and successors, jointly and severally liable.
The condition of this obligation is that principal has applied to the State of Oregon for one or more cigarette
distributor’s or wholesaler’s licenses and is required by the provisions of ORS 323.110 to furnish a bond on the terms and
conditions set forth in the Cigarette Tax Act and ORS 742.350 through 742.370.
If principal and all of principal’s agents and employees faithfully abide by the provisions of the statutes as shown
above, together with all corrective and supplementary act, then this obligation shall be null and void, otherwise, it shall be
in full effect.
This bond shall be continuous and shall remain in effect unless terminated in the manner provided by statute. In
this regard, the surety may exercise its right to withdraw as surety in writing. The withdrawal shall be effective on the first
day of the calendar month after the department receives the notice, if the notice is received on or before the 15th day of
the month. Otherwise the withdrawal shall be effective on the first day of the second calendar month after the department
receives the notice. If the surety wishes to withdraw, the surety shall remain liable for any obligation incurred by the
principal prior to the effective date of the withdrawal regardless of the due date of any tax payment.
This bond shall be effective on and after _______________________________, _______.
Executed this _______________ day of _______________________________, _______.
X
______________________________________________________________________________________________
Signature of principal
Title
Phone number
X
______________________________________________________________________________________________
Signature of surety
Title
Phone number
Mail to:
Cigarette Tax
Oregon Department of Revenue
Po Box 14630
Salem OR, 97309-5050
150-105-003 (Rev. 12-14)
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