OREGON – PACT ACT REPORT 1 DM #8734699
DM #8734699 Updated : 1-25-18
Report of Shipments for the
Month Ending:
____________, 20________
Due the 10
th
Day of the Calendar Month
STATE OF OREGON
PACT ACT
Tobacco Product Sales
PART 1: BUSINESS INFORMATION
Business Name: Contact Person: FEIN:
Address:
City: State: Zip Code:
Telephone Number: Email Address:
PART 2: REPORTING METHOD
Please Check the Appropriate Box:
No Sales in Interstate Commerce Copies of Invoices Attached (____Pages)
Memorandum of Shipments (Part 4) Attached (____ Pages) Memorandum of Shipments Submitted Electronically
PART 3: SIGNATURE OF AUTHORIZED REPRESENTATIVE
Authorized Representative: Title:
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 provide is true and
correct.
Signature: ________________________________
Date: ____________________________________
Complete and Return to:
Oregon Dept. of Revenue Oregon Dept. of Justice
Attn: Special Programs Admin. Attn: Tobacco Enforcement
P.O. Box 14630 AND 1162 Court St. NE
Salem, OR 97309 Salem, OR 97301
rochelle.nave@oregon.gov dena.spaulding@doj.state.or.us
