Fillable Olcc Direct Shipper Quarterly Statement (Page 2 of 2) in pdf

Olcc Direct Shipper Quarterly Statement Page 2

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CLEAR

DIRECT SHIPPER QUARTERLY STATEMENT

Tax Report of Malt Beverage, Cider and Wine Shipped Residents Within the State of Oregon

YEAR

Trade Name ______________________________________ YEAR__________

JAN-MAR

JUL-SEP



Premises Address _________________________________________________

APR-JUN

OCT-DEC



City ________________________ State ______

OLCC License Number __________________________

(A)

(B)

(C)

MALT/CIDER

WINE

(Barrels)

14% & UNDER

OVER 14%

(Gallons)

1. Taxable Product Shipped to Oregon Residents

2. Authorized Deductions (Schedule 12)

3. Total Taxable Distribution

(Line 1 Minus Line 2)

4. Rate of Tax

$ 2.60

$ 0.67

$ 0.77

5. Amount of Tax (Line 3 x 4)

6. TOTAL TAX (Total of Columns A, B, & C - Line 5)

7. Other Additions (or Deductions)

8. Penalty - 10%of Delinquent Tax of Late Payment

9. Interest - 1% of Delinquent Tax Per Month

10. Audit Adjustments - Charges (or Credits)

11. TOTAL TAX, PENALTY and OTHER ITEMS DUE

(Total of Lines 6 through 10) - Enclose Remittance

Certiﬁ cation

I certify that I am the duly appointed and qualiﬁ ed _____________________________ of the _________________________________

(Ofﬁ icial Position)

(Licensee)

and that the foregoing statement, with accompanying schedules, is a full, true, and complete report of malt/cider and wine directly

shipped to Oregon residents by said permit holder during the period above stated.

____________________________

___________________________________________ ________________________________

(Phone Number)

(Signature)

(Print Name)

NOTE: Reports for the preceding calendar quarter are due on or before the 20th day of January, April, July & October, if not

paid a penalty of 10% and interest at the rate of 1% a month of fraction of a month shall be added and collected.

Mail Reports to:

OREGON LIQUOR CONTROL COMMISSION

PRIVILEGE TAX SECTION

PO BOX 22297, MILWAUKIE, OREGON 97269-2297

For OLCC Accounting Use Only

Control Number __________________________ Over........................................ $____________________________

DS1 QTR (Rev. 1/16) ______________________ Short......................................

$____________________________

Olcc Direct Shipper Quarterly Statement Page 2

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