IN-STATE CIGARETTE DISTRIBUTOR
Mail this return to:
DEPARTMENT USE ONLY
Form
Date Received
Cigarette Tax
Quarterly Reconciliation Report
511
Oregon Department of Revenue
Tax Year 2003
PO Box 14110
Salem OR 97309-0910
Quarter Ending __________________ Due Date __________________
Distributor
Federal ID Number
License Number
Business ID Number (BIN) Program
Year
Period
Liability
•
•
•
•
•
•
511
03
1
Street Address
City
State
ZIP Code
COLUMN A
COLUMN B
COLUMN C
COLUMN D
COLUMN E
OR
PART 1—CIGARETTE STOCK SUMMARY
No. Cigarettes Single Stick
No. Cigarettes 10-Pack
No. Cigarettes 20-Pack
No. Cigarettes 25-Pack
Total Number of Cigarettes
1. Beginning inventory of unstamped cigarettes (from line 3, previous return)
(include those cigarettes with other states’ stamps affixed)
2. Total cigarettes received from manufacturers
(attach Schedule A, form 150-105-053)
3. Subtract ending inventory of unstamped cigarettes
(include those cigarettes with other states’ stamps affixed)
4. Total cigarettes distributed during reporting period
5. Subtract tax exempt distribution and prestamped cigarettes
(attach Schedule C, form 150-105-052)
6. Oregon Taxable Distribution (attach Schedule B, form 150-105-054)
PART 2—TAX VALUE OF UNAFFIXED STAMPS
$0.64 Stamps
$1.28 Stamps
$1.60 Stamps
Total Tax Value All Indicia
7. Beginning inventory tax value of unused stamps (from line 9, previous return)
$
$
$
$
8. Tax value of stamps purchased during reporting period
$
$
$
$
9. Subtract ending inventory tax value of unused stamps
$
$
$
$
10. Total tax value of stamps used during reporting period
$
$
$
$
11. Subtract tax value of stamps cancelled by an agent of the department during reporting
$
$
$
$
period (use gross tax value from form 150-105-029, Cigarette Tax Refund Certificate)
12. Total tax value of stamps used during reporting period (total tax paid)
$
$
$
$
13. Total tax due (line 6, Column E above x 0.064)
$
14. Difference: Line 13 minus line 12
$
Under penalties for false swearing, I declare that I have examined this report, including accompanying schedules and statements. To the best of my knowledge and belief, it is true, correct, and complete.
Signature
Title
Telephone Number
Date
(
)
X
150-105-051 (Rev. 1-03) Web