Form 150-105-057 - Out-Of-State Cigarette Distributor Quarterly Reconciliation Report - Oregon Department Of Revenue - 2001 Page 2

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Record of Shipment of
UNSTAMPED Cigarettes and Little Cigars
into Oregon
Please record the following information on this form:
•
Shipment of unstamped cigarettes and little cigars sent to instate distributors.
•
Shipment of exempt cigarettes and little cigars into Oregon.
Number of
Date of Shipment
Name and Address of Purchaser
Invoice Number
Cigarettes
150-105-057 (Rev. 2-01) back

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