Form 514 - Oregon Cigarette Consumer'S Monthly Tax Report - 2010
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1Clear Form
2010
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
10
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
11/28/09
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 (Rev. 12-09)
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