Form DM1283783 "Brand Specific Report for Cigarettes, Roll-Your-Own, and Little Cigars Products With Oregon Tax Paid for All Manufacturers" - Oregon

What Is Form DM1283783?

This is a legal form that was released by the Oregon Department of Justice - a government authority operating within Oregon. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on February 8, 2018;
  • The latest edition provided by the Oregon Department of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DM1283783 by clicking the link below or browse more documents and templates provided by the Oregon Department of Justice.

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Download Form DM1283783 "Brand Specific Report for Cigarettes, Roll-Your-Own, and Little Cigars Products With Oregon Tax Paid for All Manufacturers" - Oregon

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BRAND SPECIFIC REPORT FOR CIGARETTES, ROLL-YOUR-OWN, AND LITTLE CIGARS
PRODUCTS WITH OREGON TAX PAID FOR ALL MANUFACTURERS
Part 1:
Company Information and Reporting Period
******SEE INSTRUCTIONS FOR DETAILS ON
For the Month of ________________________________, 20_______
HOW TO COMPLETE THIS FORM – PRINT OR
TYPE ALL INFORMATION*****
LICENSE NO:____________________________ (FEIN):
Business Name:
PLEASE REFER TO OREGON’S DIRECTORY
Physical Address:
OF COMPLIANT TOBACCO
Mailing Address:
MANUFACTURERS AND BRANDS AT
www.doj.state.or.us/tobacco
FOR THE
Phone No.:____________________________________ Fax No.:
CORRECT TOBACCO BRAND
Email:
MANUFACTURER.
Name of Person Completing Form:
Phone and Email of Person Completing Form:
Part 2:
Sales Information and Certification
This form is due 15 days after the close of the
reporting month.
You Must Check at Least One Box:
Please return completed form to:
No sales to Report this month.
State of Oregon
Sales of PM products are shown in Section 3.
Department of Justice
Sales of NPM products where you affixed stamps and/or paid taxes are shown in Section 4.
Civil Recovery – Tobacco Enforcement
1162 Court Street NE
Section 3 and/or 4 submitted electronically. (Original page 1 with signature will be mailed).
Salem, OR 97301-4096
Email: tobaccoenforcementBSR@doj.state.or.us
Under penalties of false swearing, I declare that I have examined this report, and any additional
reports submitted in written or electronic form, and to the best of my knowledge and belief the
information provided is true, correct, and complete.
**** ELECTRONIC SUBMISSION***
For information on submitting Part 3 and Part 4
electronically, contact the tobacco unit at:
Print Name
tobaccoenforcementBSR@doj.state.or.us
X
Date
Signature of Distributor or Representative
OREGON – Page 1
DM #1283783(2/8/2018)
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Save
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BRAND SPECIFIC REPORT FOR CIGARETTES, ROLL-YOUR-OWN, AND LITTLE CIGARS
PRODUCTS WITH OREGON TAX PAID FOR ALL MANUFACTURERS
Part 1:
Company Information and Reporting Period
******SEE INSTRUCTIONS FOR DETAILS ON
For the Month of ________________________________, 20_______
HOW TO COMPLETE THIS FORM – PRINT OR
TYPE ALL INFORMATION*****
LICENSE NO:____________________________ (FEIN):
Business Name:
PLEASE REFER TO OREGON’S DIRECTORY
Physical Address:
OF COMPLIANT TOBACCO
Mailing Address:
MANUFACTURERS AND BRANDS AT
www.doj.state.or.us/tobacco
FOR THE
Phone No.:____________________________________ Fax No.:
CORRECT TOBACCO BRAND
Email:
MANUFACTURER.
Name of Person Completing Form:
Phone and Email of Person Completing Form:
Part 2:
Sales Information and Certification
This form is due 15 days after the close of the
reporting month.
You Must Check at Least One Box:
Please return completed form to:
No sales to Report this month.
State of Oregon
Sales of PM products are shown in Section 3.
Department of Justice
Sales of NPM products where you affixed stamps and/or paid taxes are shown in Section 4.
Civil Recovery – Tobacco Enforcement
1162 Court Street NE
Section 3 and/or 4 submitted electronically. (Original page 1 with signature will be mailed).
Salem, OR 97301-4096
Email: tobaccoenforcementBSR@doj.state.or.us
Under penalties of false swearing, I declare that I have examined this report, and any additional
reports submitted in written or electronic form, and to the best of my knowledge and belief the
information provided is true, correct, and complete.
**** ELECTRONIC SUBMISSION***
For information on submitting Part 3 and Part 4
electronically, contact the tobacco unit at:
Print Name
tobaccoenforcementBSR@doj.state.or.us
X
Date
Signature of Distributor or Representative
OREGON – Page 1
DM #1283783(2/8/2018)
PART 3 - PARTICIPATING MANUFACTURERS (A ach addi onal sheets if needed)
COLUMN B                        
COLUMN F       
MANUFACTURER IF DIFFERENT 
COLUMN C                        
COLUMN D                        
COLUMN E       
NUMBER OF 
COLUMN G      
THAN PURCHASED FROM/Name, 
PURCHASED FROM/Name, 
SOLD TO/Customer Name, 
NUMBER OF 
ROLL ‐YOUR‐
NUMBER OF 
COLUMN A      
Address, Country, Telephone 
Address, Country, Telephone 
Address, Country, Telephone 
CIGARETTES 
OWN SOLD      
LITTLE CIGARS 
BRAND NAME
Number
Number
Number
SOLD
(OUNCES)
SOLD
PART 4 - NON-PARTICIPATING MANUFACTURERS (A ach addi onal sheets if needed)
COLUMN B                        
COLUMN F       
MANUFACTURER IF DIFFERENT 
COLUMN C                        
COLUMN D                        
COLUMN E       
NUMBER OF 
COLUMN G      
THAN PURCHASED FROM/Name, 
PURCHASED FROM/Name, 
SOLD TO/Customer Name, 
NUMBER OF 
ROLL ‐YOUR‐
NUMBER OF 
COLUMN A      
Address, Country, Telephone 
Address, Country, Telephone 
Address, Country, Telephone 
CIGARETTES 
OWN SOLD      
LITTLE CIGARS 
BRAND NAME
Number
Number
Number
SOLD
(OUNCES)
SOLD
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