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Oregon Department of Revenue
5 Form OR-CAT-V 5
6 Oregon Corporate Activity 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 begins (MM/DD/YYYY) Tax year ends (MM/DD/YYYY) 9
10 10
11 99/99/9999/ / 99/99/9999/ / 11
12 12
13 Legal name of designated CAT entity (sole proprietor—complete First name and Last name lines below) 13
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
16 Federal employer identification number (FEIN) 16
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99-9999999
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20 First name Initial 20
21 21
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XXXXXXXXXXXXXXXX X
23 Last name 23
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
26 Social Security number (SSN) 26
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999-99-9999
29 29
30 Designated CAT entity address 30
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
33 City State ZIP code 33
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35 XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX - 35
36 Country (if other than U.S.) 36
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XXXXXXXXXXXXXXXXXXXXX
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40 Contact first name Initial Contact last name 40
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XXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
43 Contact phone 43
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999-999-9999
46 Payment type (check one) 46
47 47
48 X Original return 48
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50 X Estimated payment 50
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52 Mail your payment to: X Amended return 52
53 53
54 Oregon Department of Revenue 54
PO Box 14950
55 Salem OR 97309-0950 55
56 56
57 Enter payment amount 57
58 58
59 150-106-172 59
(Rev. 06-29-21, ver. 03)
60 9999 99 $ , 99,999,999.00, 0 0 60
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63 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 63
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