Form 511 - Out-Of-State Cigarette Distributor Quarterly Reconciliation Reports - 2012
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Oregon
Department of Revenue Use Only
Form
Date received
Out-of-State Cigarette Distributor
511
Quarterly Reconciliation Report
Tax Year 2012
Quarter ending __________________ Due date __________________
This form is for use by Oregon-licensed distributors whose business firm is located outside Oregon. The report must be
filed quarterly, regardless of whether there is activity in the quarter.
Federal employer identification no. (FEIN)
License number
Business identification no. (BIN)
Program code
Year
Period
Liability
•
•
•
•
•
•
511
12
03
1
-
Distributor
Address (street)
City
State
ZIP code
A. Oregon taxable distribuion
20-pack
25-pack
1. Number of cigarette packs shipped
into Oregon this period.
2. Subtract beginning inventory of
stamped packs.
3. Add ending inventory of stamped
packs.
4. Total number of packs stamped this
period.
B. Oregon stamp reconciliation
$1.18 Stamps
$1.475 Stamps
1. Beginning inventory of unused Oregon
stamps (from line 4, previous return)
2. Number of stamps
Date
purchased during this
quarterly reporting period
Date
(list by date and quantity)
Date
Date
Date
Date
Date
3. Total of line 1 and line 2
(
)
(
)
4. Ending inventory of unused
Oregon stamps
5. Total Oregon stamps used during
reporting period (line 3 minus line 4)
Under penalties for false swearing, I declare that I have examined this return, including any accompanying schedules and
statements. To the best of my knowledge and belief it is true, correct, and complete.
Signature of distributor
Title
Telephone number
Date
(
)
X
/
/
File this form on or before the 20th day following this reporting period.
Send to: Cigarette Tax, Oregon Department of Revenue, PO Box 14110, Salem OR 97309-0910
150-105-057 (Rev. 12-11)
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