Clear Form
REVENUE USE ONLY
2007
Form
Date Received
•
514
OREGON CIGARETTE CONSUMER’S
Payment Received
•
MONTHLY TAX REPORT
Reporting Period
Social Security Number
Oregon Business Identifi cation Number
Program Code
Year
Period
Liability
•
•
•
•
•
•
514
07
1
Month:
Name
Mailing Address
City
State
ZIP Code
• Please use blue or black ink when fi lling out this form.
• You must fi le a separate Form 514 for each month that you made purchases.
• Please read instructions on the back of this form before fi lling out Schedule A.
• Complete Schedule A before fi lling in lines 1– 5.
Schedule A.
List all cigarettes purchased for the month you are reporting (add additional pages if needed).
Invoice
Total number
Distributor from whom cigarettes were purchased
of cigarettes
Number
Date
A. Total number of cigarettes. (This total also needs to be entered on line 1 below.) .............. Box A
Note: The amount on line 1 is the total number of cigarettes purchased, not cigarette packs or cartons.
1. Total number of cigarettes (from Schedule A, box A) .................................................................. 1
× 0.059
2. Tax rate (per cigarette) ................................................................................................................ 2
•
3. Tax due (multiply line 1 by 0.059) ................................................................................................ 3
4. Penalty and interest (see instructions) ......................................................................................... 4
5. Total due (add lines 3 and 4)....................................................................................................... 5
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
Date
PRINT Name Signed Above
Title
Telephone Number
(
)
150-105-013 (Rev. 12-06) Web
Please read the instructions on the back
1
2
