Application For Deferred Payment Of Cigarette Tax Form December 2009
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DEPARTMENT OF REVENUE USE ONLY
Date received
APPLICATION FOR
DEFERRED PAYMENT OF CIGARETTE TAX
Business name
Federal employer identification number (FEIN)
Business identification number (BIN)
ZIP code
Physical street address
City
State
License number
Mailing address
ZIP code
Telephone number
City
State
(if different than above)
(
)
As provided in Oregon Revised Statute 323.175, the undersigned, a duly licensed Oregon ciga-
rette 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
Address (City, state, ZIP code)
Amount of bond*
$
* 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 se-
curities 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. 12-09)
Mail completed application for deferred payment and surety bond to:
CIGARETTE TAX
OREGON DEPARTMENT OF REVENUE
PO BOX 14630
SALEM OR 97309-5050
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