Form 201 Fp - Forest Products Harvest Tax Return Sample (2004) - Oregon Department Of Revenue Page 25

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Form
SMALL TRACT FORESTLAND SEVERANCE TAX
DEPARTMENT USE ONLY
391
Date Received
EASTERN OREGON
EO
Payment Amount
2004
1
2
3
12058888
Business Identifi cation Number (BIN)
NO HARVEST – Check here, sign,
and return form.
SAMPLE TAXPAYER
Amended Return
200 ANY STREET
EXAMPLE CITY OR 97801
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
60
2004-971-85008-01
STF-EO
31
2S
38E
01
60
2004-971-85009-01
STF-EO
31
3S
39E
01
60
2004-971-85010-01
STF-EO
31
3S
37E
01
No Harvest
2004-971-85011-01
STF-EO
31
2S
38E
04
No Harvest
2004-971-85012-01
STF-EO
31
2S
39E
04
No Harvest
2004-971-85013-01
STF-EO
31
3S
39E
04
10
2004-971-85014-01
STF-EO
31
2S
39E
02
10
2004-971-85015-01
STF-EO
31
2S
39E
03
No Harvest
2004-971-85016-01
STF-EO
31
2S
38E
04
8
Total Volume
220
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
3.03
Make check or money order payable to:
9
Oregon Department of Revenue
Tax
666.60
(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
666 60
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
666 60
541
999-7777
January 15, 2005
(
)
(Add boxes 11, 13, and 14)
—KEEP A COPY OF THIS RETURN FOR YOUR RECORDS—
150-391-001 (7-04)
25
150-441-409 (Rev. 2-05)

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