Form 512 - Oregon Monthly Tax Report For Nonexempt Cigarettes For Cigarette Manufacturers - 2010

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Clear Form
OREGON MONTHLY TAX REPORT FOR
REVENUE USE ONLY
Form
For Tax Year
Date received
NONEXEMPT CIGARETTES
2010
512
For Cigarette Manufacturers
Payment received
Due date is on or before the 20th day following this reporting period
Month
Due date
Program
Year
Period
Liability
Federal employer identification number
512
10
1
Business identification number
Business name:
Mailing address:
City:
State:
ZIP:
Type of business:
Corporation
Partnership
Individual
Other: ________________________
1. Number of cigarettes distributed in Oregon ...............................................................1
x 0.059
2. Tax rate .......................................................................................................................2
$
3. Total tax (box 1 x box 2) .............................................................................................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 of authorized representative
Social Security number
Date
X
PRINT name signed above
Title
Telephone number
(
)
150-105-016 (Rev. 12-09)
Please read the instructions on the back
Mail this report on or before the due date shown above.
Mail to: CIGARETTE TAX
OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910

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