Form 514 - Oregon Cigarette Consumer'S Monthly Tax Report - 2008

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Clear Form
2008
Revenue use only
Form
Date received
514
Oregon Cigarette Consumer’s
Payment received
Monthly Tax Report
Reporting period
Social Security number (SSN)
Oregon business identification number (BIN) (only for businesses) Program code
Year
Period
Liability
514
08
1
Month:
Name
Mailing address
City
State
ZIP code
Please read the instructions on the back of this form. Example of completed form:
Invoice
Example:
D. Number
E. Packs
F.
G. Total number
Cigarettes
A. Distributor from whom cigarettes were purchased
of cartons
per carton
per pack
of cigarettes
B. Number
C. Date
Example: ABC Internet Cigarette Company
8251786-394
11/28/08
2
10
x
20
400
x
=
(do not include in total)
List all cigarettes purchased for the month you are reporting (add additional pages if needed):
Invoice
D. Number
E. Packs
F.
G. Total number
Cigarettes
A. Distributor from whom cigarettes were purchased
of cartons
per carton
per pack
of cigarettes
B. Number
C. Date
x
x
=
x
x
=
x
x
=
x
x
=
x
x
=
1. Total number of cigarettes (add numbers in column G) ... 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
PRINT name
Date
Telephone number
(
)
150-105-013 (12-07)

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