2007 Oregon Petroleum Load Fee Quarterly Return Form - Oregon Department Of Revenue Page 2

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OREgOn PEtROlEum lOad fEE
fOR OffICE uSE OnlY
date received
Quarterly Return
•
tax Year 2008
Payment received
•
Quarter
due date
Business Identification number (BIn) Program Code Year
Period
liability
3
•
•
•
•
07/01/08 to 09/30/08 October 31, 2008
550
08
09
1
Federal employer Identification number (FeIn)
Is this an amended
3rd Quarter
return? Check if yes.
telephone number
(
)
Indicate:
Bulk Facility
Bulk Facility / Seller
Importer
Seller
transporter
1. number of loads .........................................................................................................1
•
2. rate per load ..............................................................................................................2
$
4.00
3. tOtal fEE duE (multiply line 1 x line 2) ...................................................................3
•
$
0.00
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
X
PrInt name Signed above
title
telephone no.
(
)
mail this return on or before the due date shown above.
mail to: OREgOn PEtROlEum lOad fEE
OREgOn dEPaRtmEnt Of REVEnuE
PO BOX 14110
SalEm OR 97309-0910
Please do not detach voucher
Please do not detach voucher
date received at revenue
Oregon Petroleum load fee Payment Voucher
For tax Year
2008
3
150-608-002 (rev. 3-08)
3rd Quarter
Program:
550
08
9
1
due date:
October 31, 2008
Enter Payment amount
BIn:
$
0.00
Is this an amended return?
Yes
OCR FONT FOR SCANLINE USE—NEED FOR CALC FORM—DON’T DELETE

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