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)