INSTRUCTIONS DIRECT SHIPPER QUARTERLY STATEMENT
All Direct Shipper transactions must be reported on this Statement
•
Name - Trade Name as it appears on your OLCC license
•
Quarter – Quarter the report refers to
•
Year - Year report refers to
•
Address – Premises address of licensee per licensee number
•
City & State – City and State of premises address of licensee per licensee number
•
OLCC License Number – OLCC license number of current certificate
Complete the information for each column as needed
Distribution (Line 1) -Taxable product total from Schedule 11
Authorized Deductions (Line 2) – Authorized deductions totals from Schedule 12
Total Taxable Distribution (Line 3) – Line 1 Minus Line 2
Rate of Tax (Line 4) – Current Rate of tax
Amount of Tax (Line 5) - Line 3 multiplied by Line 4
Total Tax (Line 6) – Total of Columns A, B, & C – Line 5
Other Additions (or Deductions) (Line 7) – Record error letter amounts as required
Penalty (Line 8) - Penalty due on late reports or errors
Interest (Line 9) - Interest due on late reports or errors
Audit Adjustments (Line 10) - Audit adjustments as required by your audit report
Total Tax, Penalty, and Other Items Due (Line 11) – Total of Line 6 to Line 10 – Enclose remittance
Certification – Required declaration of accurate and complete statement
Official Position – Position Title for legal entity (For example, Owner, President, etc.)
Licensee – Trade Name of the company as it appears on your OLCC license
Phone Number – Number at which licensee can be reached
Signature – Signature of person listed in Official Position
Printed Name – Printed name of person listed in Official Position
This report must be completed QUARTERLY by all Direct Shippers when there are direct shipments to
Oregon residents. The report must be postmarked on or before the 20
th
of January, April, July, and
th
October following the quarter of the reporting period. When the 20
falls on a Saturday, Sunday, or a
legal holiday, the filing must be postmarked by the U. S. Postal Service no later than the next postal
business day.
When reporting Barrels/Gallons, carry the decimal to two places.
Decimals of .005 or larger should be rounded up. Example 12.387 would be reported as 12.39.
Decimals of .004 and lower should be dropped. Example 12.384 would be 12.38.
Rev 01/16