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5 Oregon Department of Revenue 5
2024 Schedule OR-21-K-1
6 Distributive Share of Proceeds, Addition, and Credit 6
7 For members of pass-through entities paying elective tax 7
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9 Page 1 of 1 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. 9
10 Part A: Pass-through entity (PTE) information 10
11 Amended 11
X
12 PTE legal name 12
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
15 Federal employer identification number (FEIN) 15
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99-9999999
18 Current address 18
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
21 City State ZIP code 21
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23 XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX - 23
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25 Part B: Member information 25
26 PTE legal name, if member is not an individual 26
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
29 Individual member first name Initial 29
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XXXXXXXXXXXXXXXX X
32 Individual member last name 32
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
35 Social Security number (SSN) FEIN 35
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999-99-9999 99-9999999
38 Current address 38
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
41 City State ZIP code 41
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43 XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX - 43
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45 Part C: Member’s distributive share of proceeds, addition, and credit 45
46 Enter the member’s share of the following items. Also include amounts passed through to an individual member from any electing lower-tier PTE. 46
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49 1. Distributive proceeds ........................................................................................1. , 999,999,999.00, 0 0 49
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52 2. Addition for tax deducted at federal level ........................................................2. , 999,999,999.00, 0 0 52
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55 3. Credit for PTE-E tax paid ..................................................................................3. , 999,999,999.00, 0 0 55
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58 —Keep this schedule with your tax records. Don’t submit with your tax return— 58
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150-107-113
63 (Rev. 08-08-24, ver. 01) 22322401010000 63
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