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Oregon Department of Revenue
5 Form OR-21-V 5
6 Pass-through Entity Elective Tax Payment Voucher 6
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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
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11 99/99/9999/ / 99/99/9999/ / 11
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13 Pass-through entity legal name 13
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
16 Contact first name Initial 16
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XXXXXXXXXXXXXXXX X
19 Contact last name 19
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22 Federal employer identification number (FEIN) 22
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99-9999999
25 Current address 25
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
28 City State ZIP code 28
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XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
31 Contact phone 31
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999-999-9999
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46 Payment type (check one) 46
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48 Want to make your payment online? Find options at www.oregon.gov/dor. Original return or extension 48
X
49 Use this voucher only if you are making a payment without a return. Make 49
50 your check, money order, or cashier’s check payable to the Oregon Department of Estimated payment 50
51 Revenue. Write “Form OR-21-V,” the filer’s name, federal employer identification X 51
number (FEIN), the tax year beginning and ending dates, and a daytime phone on
52 your payment. Don’t mail cash. Mail the voucher and payment to: X Amended return 52
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54 Oregon Department of Revenue 54
PO Box 14950
55 Salem OR 97309-0950 55
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57 Enter payment amount 57
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59 150-107-172 59
(Rev. 04-27-23, ver. 03)
60 9999 99 $ , 99,999,999.00, 0 0 60
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63 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 63
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