Form 512 - Oregon Monthly Tax Report For Nonexempt Cigarettes For Cigarette Manufacturers - 2010

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Clear Form
OREGON MONTHLY TAX REPORT FOR
REVENUE USE ONLY
Form
For Tax Year
Date received
NONEXEMPT CIGARETTES
2010
•
512
For Cigarette Manufacturers
Payment received
•
Due date is on or before the 20th day following this reporting period
Month
Due date
Program
Year
Period
Liability
Federal employer identification number
•
•
•
•
•
512
10
1
Business identification number
•
Business name:
Mailing address:
City:
State:
ZIP:
Type of business:
Corporation
Partnership
Individual
Other: ________________________
1. Number of cigarettes distributed in Oregon ...............................................................1
x 0.059
2. Tax rate .......................................................................................................................2
$
3. Total tax (box 1 x box 2) .............................................................................................3
$
4. Penalty and interest (see instructions) ........................................................................4
$
5. TOTAL DUE (add lines 3 and 4)..................................................................................5
DECLARATION
I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of
my knowledge it is true, correct, and complete.
Signature of authorized representative
Social Security number
Date
X
PRINT name signed above
Title
Telephone number
(
)
150-105-016 (Rev. 12-09)
Please read the instructions on the back
Mail this report on or before the due date shown above.
Mail to: CIGARETTE TAX
OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910

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