Form 150-608-002-2 - Oregon Petroleum Load Fee Quarterly Return - 2012
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Oregon Petroleum Load Fee
FOR OFFICE USE ONLY
Date received
Quarterly Return
•
Tax Year 2012
Payment received
•
Quarter
Due date
*
Program code Year
Period
Liability
2
Business identification number (BIN)
•
•
•
•
04/01/12 to 06/30/12 July 31, 2012
550
12
06
1
STOP!
RequiRed Field See instructions.
Federal employer identification number (FEIN)
2nd Quarter
*
RequiRed Field
*
Name
Telephone number
(
)
*
Address
Amended return?
Yes
Mailing address change? Yes
Final return?
Yes
*
*
*
City
State
ZIP code
Indicate:
Bulk facility
Bulk facility / seller
Importer
Seller
Transporter
•
1. Number of loads .........................................................................................................1
2. Rate per load ..............................................................................................................2
$
4.00
•
3. TOTAL FEE DUE (multiply line 1 x line 2) ...................................................................3
$
Under penalty of false swearing, I declare that the information in this return and any attachments is true, correct, and complete.
Signature
Date
X
PRINT name signed above
Title
Telephone number
(
)
Mail this return on or before the due date shown above.
Mail to: Oregon Petroleum Load Fee
Oregon Department of Revenue
PO Box 14110
Salem OR 97309-0910
do not detach voucher
do not detach voucher
Date received at Revenue
Oregon Petroleum Load Fee Payment Voucher
For Tax Year
2
2012
150-608-002-2 (Rev. 03-12)
2nd Quarter
Program:
550
12
6
1
Due date:
July 31, 2012
Payment amount
BIN:
$
Is this an amended return?
Yes
OCR FONT FOR SCANLINE USE—NEED FOR CALC FORM—DON’T DELETE
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Parent category: Financial