Form 201 Fp - Forest Products Harvest Tax Return Sample (2004) - Oregon Department Of Revenue Page 21

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Form
SMALL TRACT FORESTLAND SEVERANCE TAX
DEPARTMENT USE ONLY
390
Date Received
WESTERN OREGON
•
•
WO
Payment Amount
2004
•
•
1
2
3
•
•
•
•
12047777
Business Identifi cation Number (BIN)
•
NO HARVEST – Check here, sign,
and return form.
SAMPLE TAXPAYER
•
Amended Return
200 ANY STREET
EXAMPLE CITY OR 97301
•
Another Party is Responsible
(attach copy of contract)
Do not white-out, cross-out, or change printed information on the return. Attach a separate explanation of changes.
1
2
3
4
6
7
5
Range
Town ship
•
•
Landowner
Section
Volume (MBF)
Forestry Notifi cation Number (permit)
County
E or W
N or S
240
2004-771-55015-01
STF WO
20
17S
2W
02
10
2004-771-55016-01
STF WO
20
16N
2W
05
No Harvest
2004-771-55017-01
STF WO
20
17S
2W
10
10
2004-771-55018-01
STF WO
20
17S
3W
03
No Harvest
2004-771-55019-01
STF WO
20
16S
3W
04
50
2004-771-55020-01
STF WO
20
18S
1W
04
No Harvest
2004-771-55021-01
STF WO
20
18N
1W
01
No Harvest
2004-771-55022-01
STF WO
20
18N
2W
01
No Harvest
2004-771-55023-01
STF WO
20
16S
3W
02
8
Total Volume
360
Please attach a copy of any additional permit(s) that are not
•
(Total from column 7 on all pages)
printed on this form.
Tax Rate
3.89
Make check or money order payable to:
9
Oregon Department of Revenue
Tax
1,400.40
•
(Multiply box 8 X tax rate)
Mail to: Timber Tax Programs
10
Prior Payments for 2004
Prior Payments for 2004
Oregon De partment of Revenue
•
▲
PO Box 14003
11
TAX DUE WITH THIS RETURN
1,400 40
Salem OR 97309-2502
•
(Subtract box 10 from box 9)
▲
12
Overpayment
DECLARATION: Under penalties for false swearing, I declare that
•
If box 10 is greater than box 9 or if box 11 is negative
▲
I have examined this return, including accompanying schedules and
statements, and to the best of my knowledge and belief it is true,
13
Up to 3 months late, enter .05 X box 11
➧
Penalty
correct, and complete.
Over 3 months late, enter .25 X box 11
▲
Signature(s)
14
Sample Taxpayer
➧
Interest
Number of days late X .000137 X box 11
X
▲
Telephone No.
Date
15
TOTAL PAYMENT
1,400 40
503
777-2222
January 15, 2005
(
)
(Add boxes 11, 13, and 14)
▲
—KEEP A COPY OF THIS RETURN FOR YOUR RECORDS—
150-390-002 (7-04)
21
150-441-409 (Rev. 2-05)

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