Form 511 - In-State Cigarette Distributor Quarterly Reconciliation Report, Schedule A Report Of Cigarettes Received - 2003 Page 2

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Schedule A—Report of Cigarettes Received
O R E G O N
D E PA R T M E N T
File with your Cigarette Distributor Quarterly Reconciliation Report
O F R E V E N U E
Distributor
License Number
Business ID Number (BIN)
Quarter Ending
Column A
Column B
Column C
Column D
Column E
List all manufacturers and suppliers who supplied cigarettes to you for distribution
Number of
Number of
Number of
Number of
TOTAL
Cigarettes
Cigarettes
Cigarettes
Cigarettes
Date
Manufacturer or Supplier
Invoice Number
Single Pack
10-Pack
20-Pack
25-Pack
150-105-053 (Rev. 5-04) Web
TOTALS
(all columns)
Attach additional schedules if needed.
Please retain a copy of each schedule for your records.
Carry totals from all columns to the Quarterly Reconciliation Report, Part 1, line 2.

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