Oregon Oregon Unlicensed Cigarette and Little Cigar Monthly Tax Report

Oregon Unlicensed Cigarette and Little Cigar Monthly Tax Report
2023 Form OR-514, Oregon Unlicensed Cigarette and Little Cigar Monthly Tax Report, 150-105-013
Clear Form
Form

OR-514

2023

Oregon Unlicensed Cigarette and Little Cigar
Monthly Tax Report

03242301010000
Revenue use only

• Date received

(For unlicensed individual or business)

• Payment received

Due date is the 20th of the month following purchase
Period end date

Federal employer identification number (FEIN)

Oregon license number

Social Security number (SSN)

Business name (complete if reporting with a FEIN)
First name (complete if reporting with a SSN)

Initial

Last name

Address

City

Contact person

Contact phone

Amended

New name

State

ZIP code

New mailing address

List all sticks purchased for the month you are reporting (add additional pages if needed):
Invoice
A. Cigarette or little cigar distributor

B. Number

C. Date

D. Number of
cartons

E. Packs
per carton

F. Sticks
per pack

				
x		 
x		
				
x		 
x		
				
x		 
x		
				
x		 
x		
				
x		 
x		

G. Total number
of sticks

=
=
=
=
=

1. Total number of sticks (add numbers in column G)..............................1.
2. Tax rate (per sticks)..............................................................................2.
3. Tax due (multiply line 1 by line 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
Print name

150-105-013 (Rev. 08-16-22, ver. 01)

Date
Title

Phone

x 0.1665