OREGON – Page 1 DM #1283783(2/8/2018)
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
For the Month of ________________________________, 20_______
LICENSE NO:____________________________ (FEIN):
Business Name:
Physical Address:
Mailing Address:
Phone No.:____________________________________ Fax No.:
Email:
Name of Person Completing Form:
Phone and Email of Person Completing Form:
Part 2: Sales Information and Certification
You Must Check at Least One Box:
□ No sales to Report this month.
□ Sales of PM products are shown in Section 3.
□ Sales of NPM products where you affixed stamps and/or paid taxes are shown in Section 4.
□ Section 3 and/or 4 submitted electronically. (Original page 1 with signature will be mailed).
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.
Print Name
X Date
Signature of Distributor or Representative
******SEE INSTRUCTIONS FOR DETAILS ON
HOW TO COMPLETE THIS FORM – PRINT OR
TYPE ALL INFORMATION*****
PLEASE REFER TO OREGON’S DIRECTORY
OF COMPLIANT TOBACCO
MANUFACTURERS AND BRANDS AT
www.doj.state.or.us/tobacco FOR THE
CORRECT TOBACCO BRAND
MANUFACTURER.
This form is due 15 days after the close of the
reporting month.
Please return completed form to:
State of Oregon
Department of Justice
Civil Recovery – Tobacco Enforcement
1162 Court Street NE
Salem, OR 97301-4096
Email: tobaccoenforcementBSR@doj.state.or.us
**** ELECTRONIC SUBMISSION***
For information on submitting Part 3 and Part 4
electronically, contact the tobacco unit at:
tobaccoenforcementBSR@doj.state.or.us
