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5           2023 Schedule OR‑OC‑3                                                                                                        Office use only                5
6           Page 1 of 1, 150-101-148   Oregon Department of Revenue                              20712301010000                                                         6
7           (Rev. 09-07-23 ver. 01)                                                                                                                                     7
8           CPAR Adjustments Report for Individuals, Fiduciaries, and Tiered Partners                                                                                   8
9                                                                                                                                                                       9
10                                                                                                                                                                      10
11                                                Submit original form—do not submit photocopy.                                                                         11
12          Pass-through entity name                                                                         Federal employer identification number (FEIN)              12
13          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                              99-9999999                                               13
14          Owner information (see instructions)                                                                                                                        14
15          1. Owner type              First name                              Initial Last name                                    Social Security number (SSN)        15
16          XXXXXXXXXXXXXXX            XXXXXXXXXXXX                       X            XXXXXXXXXXXXXXXXXXXX                         999-99-9999                     16
17          Fiduciary name                                                                                   FEIN                                                       17
18          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                              99-9999999                                               18
19          Ownership percentage       Share of federal CPAR adjustments               Share of Oregon-source CPAR adjustments                                          19
20          999.9999.                % 99,999,999,999.00.00                            99,999,999,999.00.00                                                             20
21                                                                                                                                                                      21
22          (a) CPAR tax                                                                                                                                                22
23                                                                                                                                                                      23
            99,999,999,999.00.00
24                                                                                                                                                                      24
25          2. Owner type              First name                              Initial Last name                                    SSN                                 25
26          XXXXXXXXXXXXXXX            XXXXXXXXXXXX                       X            XXXXXXXXXXXXXXXXXXXX                         999-99-9999                     26
27          Fiduciary name                                                                                   FEIN                                                       27
28          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                              99-9999999                                               28
29          Ownership percentage       Share of federal CPAR adjustments               Share of Oregon-source CPAR adjustments                                          29
30          999.9999.                % 99,999,999,999.00.00                            99,999,999,999.00.00                                                             30
31                                                                                                                                                                      31
32          (a) CPAR tax                                                                                                                                                32
33                                                                                                                                                                      33
            99,999,999,999.00.00
34                                                                                                                                                                      34
35          3. Owner type              First name                              Initial Last name                                    SSN                                 35
36          XXXXXXXXXXXXXXX            XXXXXXXXXXXX                       X            XXXXXXXXXXXXXXXXXXXX                         999-99-9999                     36
37          Fiduciary name                                                                                   FEIN                                                       37
38          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                              99-9999999                                               38
39          Ownership percentage       Share of federal CPAR adjustments               Share of Oregon-source CPAR adjustments                                          39
40          999.9999.                % 99,999,999,999.00.00                            99,999,999,999.00.00                                                             40
41                                                                                                                                                                      41
42          (a) CPAR tax                                                                                                                                                42
43                                                                                                                                                                      43
            99,999,999,999.00.00
44                                                                                                                                                                      44
45          4. Owner type              First name                              Initial Last name                                    SSN                                 45
46          XXXXXXXXXXXXXXX            XXXXXXXXXXXX                       X            XXXXXXXXXXXXXXXXXXXX                         999-99-9999                     46
47          Fiduciary name                                                                                   FEIN                                                       47
48          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                              99-9999999                                               48
49          Ownership percentage       Share of federal CPAR adjustments               Share of Oregon-source CPAR adjustments                                          49
50          999.9999.                % 99,999,999,999.00.00                            99,999,999,999.00.00                                                             50
51                                                                                                                                                                      51
52          (a) CPAR tax                                                                                                                                                52
53                                                                                                                                                                      53
            99,999,999,999.00.00
54                                                                                                                                                                      54
55          5. Total CPAR tax                                                                                                                                           55
56          Total column (a)                                                                                                                                            56
57                                                                                                                                                                      57
            99,999,999,999.00.00
58                                                                                                                                                                      58
59          Include this schedule with your Form OR‑OC.                                                                                                                 59
60          Use additional copies of this page for additional individuals, fiduciaries, and tiered partners.                                                            60
61          If using more than one page, total all pages on line 5 of the first page.                                                                                   61
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63                                                                                                                                       Page _______ 999 of _______999 63
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