Oregon Form Ds1 – Fill Out and Use This PDF

DIRECT SHIPPER STATEMENT

Address
City					State				OLCC License Number
								(A)	(B)		(C)
								CIDER	WINE		WINE
								(Barrels)	14% & UNDER		OVER 14%
									(Gallons)		(Gallons)
1.	Taxable Product Shipped to Oregon Resident (Schedule 11)
2.	Authorized Deductions (Schedule 12)
3.	Total Taxable Distribution
	(Line 1 Minus Line 2)
4.	Rate of Tax							$ 2.60	$ 0.67		$ 0.77
5.	Amount of Tax (Line 3 x 4)							$	$		$
6.	TOTAL TAX (Total of Columns A, B, & C - Line 5)										$
7.	Other Additions (or Deductions)										$
8.	Penalty - 10% of Delinquent Tax of Late Payment										$
9.	Interest - 1% of Delinquent Tax per Month or Fraction of a Month										$
10.	Audit Adjustments - Charges (or Credits)										$
11. TOTAL TAX, PENALTY and OTHER ITEMS DUE
	(Total of Lines 6 through 10) - Enclose Remittance										$
								Certification

I certify that I am the duly appointed and qualified ______________________________ of the ____________________________________________________________

(Official Position)

(Licensee)

and that the foregoing statement, with accompanying schedules, is a full, true, and complete report of cider and wine directly shipped to Oregon residents by said permit holder during the month or period above stated.

(Phone Number)

(Signature)

(Printed Name)

NOTE : Reports for the preceding calendar month are due on or before the 20th day of each month, if not paid a penalty of 10% and interest at the rate of 1% a month or fraction of a month shall be added and collected.

OREGON LIQUOR CONTROL COMMISSION

Mail Reports To:		PRIVILEGE TAX SECTION
		PO BOX 22297
		MILWAUKIE, OREGON 97269-2297
			For O.L.C.C. Accounting Use Only
Control Number			Over	. .	$

DS1 (Est. 7/07)

Short

$

INSTRUCTIONS DIRECT SHIPPER STATEMENT

All Direct Shipper transactions must be reported on this Statement.

Name - Trade Name as it appears on your OLCC license

Month - Month report refers to

Year - Year report refers to

Address - Physical address of Licensed Premise (do not enter mailing address)

City & State - City and State of premise physical address

OLCC License Number - OLCC license number of current certificate

Complete the information for each column as needed. Taxable Product shipped into Oregon (Line 1) -Taxable product total from Schedule 11 Authorized Deductions (Line 2) - Authorized deductions totals from Schedule 12 Total Taxable Distribution (Line 3) - Line 1 Minus Line 2

Rate of Tax (Line 4) - Current Rate of tax

Amount of Tax (Line 5) - Line 3 multiplied by Line 4 Total Tax (Line 6) - Total of Columns A, B & C - Line 5

Other Additions (or Deductions) (Line 7) - Adjustments regarding error letters received from OLCC Penalty (Line 8) - Penalty due on late reports or errors

Interest (Line 9) - Interest due on late reports or errors

Audit Adjustments (Line 10) - Audit adjustments as indicated on your audit report

Total Tax, Penalty and Other Items Due (Line 11) - Total of Line 6 to Line 10 - Enclose remittance

Certification - Required declaration of accurate and complete statement

Official Position - Position Title for legal entity (For example, Owner, President, etc.) Licensee - Trade Name of the company as it appears on your OLCC license Phone Number - Number at which licensee can be reached

Signature - Signature of person listed in Official Position Printed Name - Printed name of person listed in Official Position

This report must be completed monthly by all Direct Shippers. The report must be postmarked on or before the 20th of the month following the reporting period. When the 20th falls on a Saturday, Sunday, or a legal holiday, the filing must be postmarked by the U. S. Postal Service no later than the next postal business day.

When reporting Barrels/Gallons, carry the decimal to two places.

Decimals of .005 or larger should be rounded up. Example 12.387 would be reported as 12.39.

Decimals of .004 and lower should be dropped. Example 12.384 would be 12.38.

DS1 Instructions (07/07)