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                                                                                                           Oregon Department of Revenue
5                     Form OR-LTD-V                                                                                                                                     5
6                     LTD Self-employment Tax Payment Voucher                                                                                                           6
7                                                                                                                                                                       7
8                     Page 1 of 1 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.           8
9           Tax year beginning (MM/DD/YYYY)               Tax year ending (MM/DD/YYYY)                                                                                  9
10                                                                                                                                                                      10
11          99/99/9999/      /                            99/99/9999/      /                                                                                            11
12                                                                                                                                                                      12
13          First name (if filer is an individual)                           Initial                                                                                    13
14                                                                                                                                                                      14
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            XXXXXXXXXXXXXXXX                                                 X
16          Last name                                                                                                                                                   16
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19          Social Security number (SSN)                                                                                                                                19
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            999-99-9999
22          Partnership name (if filer is a partnership)                                                                                                                22
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
25          Federal employer identification number (FEIN)                                                                                                               25
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            99-9999999
28          Business address                                                                                                                                            28
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
31          City                                                                               State       ZIP code                                                     31
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            XXXXXXXXXXXXXXXXXXXXXX                                                             XX          XXXXX-XXXX
34          Contact phone                                                                                                                                               34
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            999-999-9999
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46                                                                                             Payment type (check one)                                                 46
47                                                                                                                                                                      47
48          Want to make your payment online? Find options at www.oregon.gov/dor.              X Original return or extension                                           48
49                                                                                                                                                                      49
            Use this voucher only if you’re sending a payment separate from a return. Make 
50          your check, money order, or cashier’s check payable to the Oregon Department       X Prepayment                                                             50
51          of Revenue. Write “Form OR-LTD-V,” the filer name, filer SSN or FEIN, the tax year                                                                          51
            beginning and ending dates, and a daytime phone on your payment. Don’t mail 
52          cash. Mail the voucher and payment to:                                             X Amended return                                                         52
53                                                                                                                                                                      53
54          Oregon Department of Revenue                                                                                                                                54
55          PO Box 14950                                                                                                                                                55
            Salem OR 97309-0950
56                                                                                                                                                                      56
57                                                                                             Enter payment amount                                                     57
58                                                                                                                                                                      58
59                                                 150-560-172                                                                                                          59
                                                   (Rev. 05-10-23, ver. 03)
60                                                                         9999 99             $           ,            99,999,999.00,                        0 0       60
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63                                                             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                       63
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