Application For Deferred Payment Of Cigarette Tax Form 2001
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1DEPARTMENT OF REVENUE USE ONLY
Date Received
O R E G O N
D E PA R T M E N T
APPLICATION FOR
O F R E V E N U E
DEFERRED PAYMENT OF CIGARETTE TAX
Business Name
Federal Identification Number
Business Identification Number
Physical Street Address
City
State
ZIP Code
License Number
Mailing Address
City
State
ZIP Code
(if different than above)
Telephone Number
(
)
As provided in Oregon Revised Statute 323.175, the undersigned, a duly licensed Oregon
cigarette distributor, hereby applies for deferred payment of Cigarette Tax in an amount not to
exceed $___________________________ in any one calendar month.
This application is accompanied by a surety bond executed by a corporation authorized to
engage in business as a surety company in Oregon under the provisions of ORS 323.110.
Name of Surety Company
Bond Number
Amount of Bond*
Address
(City, State, ZIP Code)
$
*Note: Amount of bond must be equal to twice the
amount of estimated credit purchased in any one
month.
I understand that in lieu of a surety bond, lawful money of the United States, or acceptable
securities in an equal amount may be deposited with the State Treasurer.
Signature of Distributor or Representative
Date
X
PRINT Name Signed Above
Title
Telephone Number
(
)
150-105-002 (Rev. 3-01) Web
Send completed application for deferred payment and surety bond to:
CIGARETTE TAX
OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910
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