Form 510 - Oregon Cigarette Tax Stamp Order Form - Tax Year 2013
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Oregon Cigarette Tax Stamp Order Form
Revenue use only
Date received
Tax Year 2013
•
Form
License number
BIN number
Program code
Year
Period
Liability
Payment amount
510
•
•
510
•
13
•
•
1
•
$
Courier name
Service type
Business name
Shipping address
Remarks
City
State
ZIP code
Courier confirmation information
Cash purchase
Please mark one box:
Deferred purchase
Revenue use only
Distributor use (please complete)
Number
Purchase price of
Type of stamps
Number of stamps
Total price
of each
each roll or pad
1b
1
1a
20S—
Pads
Minimum purchase 1 pad (1,000 $1.18 stamps)
•
X
$ 1,180
=
$
#
—
2b
2
2a
Wide 20S—
Rolls
Minimum purchase 1 roll (7,200 $1.18 stamps)
•
X
$ 8,496
=
$
#
—
3b
3
3a
Rolls
Marlboro—
Minimum purchase 1 roll (7,200 $1.475 stamps)
•
X
$ 10,620
=
$
M-
M-
#
—
4a
4b
4
Rolls
Large roll—
Minimum purchase 1 roll (30,000 $1.18 stamps)
•
X
$ 35,400
=
$
#
—
5a
5
Total number of stamps
Total order
#
—
(add boxes 1–4)
$
#
—
6
Subtract discount
( total number of stamps
—
#
—
X 0.004 discount rate)
7
Net amount due
#
—
(box 5 minus box 6)
$
#
—
See next page for complete instructions. Deferred customers may fax your order to:
Cigarette Tax, 503-947-2255. Please retain a copy of your order for your records.
#
—
Distributor use
Distributor’s authorized signer
Print name
Date
Telephone number
(
)
X
/
/
Authorized signer for pick-up
Print name
Date
Telephone number
(
)
X
/
/
Revenue use only
Order entered by
Order number
Order filled by
Order verified by
Stamp Inventory System: Order input by
Date entered
Date filled
Date verified
Date
/
/
/
/
/
/
/
/
150-105-020 (Rev. 12-12)
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