Form 150-105-057 - Out-Of-State Cigarette Distributor Quarterly Reconciliation Report - Oregon Department Of Revenue - 2001
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1
2OUT-OF-STATE CIGARETTE DISTRIBUTOR
Department of Revenue Use Only
Date Received
O R E G O N
QUARTERLY RECONCILIATION REPORT
D E PA R T M E N T
Tax Year 2001
O F R E V E N U E
Quarter Ending ____________
Due Date _____________
This form is for use only by distributors whose business firm is located outside Oregon and who affix Oregon cigarette tax
stamps to cigarettes and little cigars for distribution in Oregon.
NEW: You must complete a Schedule B (Oregon Distribution Report, form 150-105-054), and file it with this report.
Federal ID No.
License No.
Business ID No. (BIN)
Program Code
Year
Period
Liability
511
01
1
Distributor
Address (street)
City
State
ZIP Code
A. Oregon Taxable Distribution
Single Sticks
10-pack
20-pack
25-pack
Total number of cigarette packs
distributed in Oregon during this
quarterly reporting period
B. Oregon Stamp Reconciliation
34-Cent Stamps
68-Cent Stamps
85-Cent Stamps
1. Beginning inventory of unused Oregon
stamps (from line 4, previous return)
Date
2. Number of stamps purchased
Date
during this quarterly
reporting period (list by
date and quantity).
Date
Date
Date
Date
Date
3. Total of lines 1 and 2
(
)
(
)
(
)
4. Ending inventory of unused Oregon stamps
5. Total Oregon stamps used during reporting period
(line 3 minus line 4)
Under penalties for false swearing, I declare that I have examined this return, including any accompanying schedules
and statements. To the best of my knowledge and belief it is true, correct, and complete.
Signature of Distributor
Title
Telephone Number
Date
(
)
X
Send to:
Cigarette Tax
File this form on or before the 20th day
Oregon Department of Revenue
following this reporting period.
PO Box 14110
Salem OR 97309-0910
150-105-057 (Rev. 2-01)
See other side . . .
to record shipment of unstamped cigarettes and little cigars.
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