REVENUE USE ONLY
Clear Form
2002
Form
Date Received
•
530
OREGON QUARTERLY TAX RETURN
Payment Received
•
FOR TOBACCO DISTRIBUTORS
Quarter
Due Date
Distributor’s License No.
Business ID No.
Program
Year
Period
Liability
1
•
•
•
•
•
03
530
02
1
01/01/02–03/31/02 April 30, 2002
Federal Identification No.
Quarter
Please use blue or black ink when filling out this form.
Type of business:
Corporation
Partnership
Individual
Other: ________________________
Complete Schedules 1 and 2 before filling in the Quarterly Tobacco Tax Return
•
1. Quarterly tobacco tax (enter amount from Schedule 1, line 7) .................. 1
•
2. Tax credit (enter amount from Schedule 2, line 12) ................................... 2
•
3. Net quarterly tax (line 1 minus line 2; not less than zero) ............................................................. 3
•
4. Quarterly tax discount (multiply line 3 by 0.015) ........................................................................... 4
•
5. Net tax due (line 3 minus line 4) ................................................................................................... 5
•
6. Penalty and interest (see instructions) .......................................................................................... 6
•
7. Total amount due (add line 5 and line 6) .................................................................................... 7
DECLARATION
I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of
my knowledge it is true, correct, and complete.
Signature
Social Security No.
Date
PRINT Name Signed Above
Title
Telephone No.
150-605-004 (Rev. 2-02) Web
Please read the instructions on the back