Oregon Emergency Communications Tax Quarterly Return

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FOR OFFICE USE ONLY
Date Received
OREGON EMERGENCY COMMUNICATIONS TAX
O R E G O N
Quarterly Return
D E PA R T M E N T
Payment Received
O F R E V E N U E
Tax Year 2002
Quarter
Due Date
Business Identification No.
Program Code
Year
Period
Liability
1
1/1/02 to 3/31/02
April 30, 2002
520
02
03
1
1st Quarter
Federal Identification No.
Telephone No.
(
)
Type of Business:
Corporation
Partnership
Individual
Other ______________
1. Total telecommunication accesses provided to 911 Emergency Reporting System
1
.75
2. Tax rate
2
$
3. TAX DUE (box 1
box 2)
3
$
4. Penalty (see instructions)
4
$
5. Interest (see instructions)
5
$
6. TOTAL DUE (add lines 3, 4, and 5)
6
DECLARATION
I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of
my knowledge it is true, correct, and complete.
Signature
Social Security Number
Date
X
PRINT Name Signed Above
Title
Telephone Number
(
)
150-603-001 (Rev. 2-02) Web
Please read the instructions on the following page
Mail this return on or before the due date shown above.
Mail to: EMERGENCY COMMUNICATIONS TAX
OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910

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