Enlarge image | 1 1 1 2 2 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 Form With grid With grid & data2 84 85 3 4 82 83 3 3 4 4 5 Form OR-19-AF Office use only 5 6 Page 1 of 1, 150-101-175 Oregon Department of Revenue 15232501010000 6 7 (Rev. 09-04-24, ver. 01) 7 8 Oregon Affidavit 8 9 9 For a nonresident owner of a pass-through entity 10 10 11 Submit original form—do not submit photocopy 11 12 Beginning with tax year: 2025 12 13 Nonresident owner information 13 14 Nonresident owner first name Initial Last name Social Security number (SSN) 14 15 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 15 16 Entity name Federal employer identification number (FEIN) 16 17 99-9999999– 17 18 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet or mailing address 18 19 19 20 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCity State ZIP code Phone 20 21 XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 999-999-9999– – 21 22 Ownership percentage Estimated Oregon-source distributive income each year 22 23 999.9999. % $ 99,999,999,999.00.00 23 24 24 25 25 26 Pass-through entity information 26 27 Pass-through entity (PTE) name FEIN 27 28 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 28 29 PTE address 29 30 30 31 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCity State ZIP code Phone 31 32 XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 999-999-9999- – - – 32 33 This form must be resubmitted if the PTE information entered above changes or if the ownership percentage of an owner that has filed an 33 34 affidavit changes by 10 percent or more. See Form OR‑19‑AF Instructions. 34 35 Agreement to file 35 36 I agree to timely file all required Oregon income or excise tax return(s) and to make timely payments of all taxes imposed by 36 37 the state of Oregon with respect to my share of the Oregon distributive income from the pass-through entity named above. I 37 38 understand that I am subject to the jurisdiction of the state of Oregon for purposes of the collection of unpaid income 38 39 tax, together with related penalties and interest. 39 40 40 41 Signature 41 42 Taxpayer or authorized agent signature Date 42 43 X 99/99/9999/ / 43 44 Revocation of this affidavit 44 45 By signing below, I declare that: 45 46 46 47 X I am an Oregon resident; 47 48 48 49 X I am subject to tax on the income from the above-listed PTE; 49 50 50 51 X I am no longer an owner in the above-listed PTE; or 51 52 52 53 X I am joining in the filing of an Oregon composite return. 53 54 54 55 Signature 55 56 Taxpayer or authorized agent signature Date 56 57 X 99/99/9999/ / 57 58 58 59 Submit this form at www.oregon.gov/dor using Revenue Online or mail to: 59 60 60 61 Oregon Department of Revenue 61 62 Attn: Processing Center 62 63 955 Center St NE 63 64 Salem OR 97301-2555 64 1 2 65 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 65 84 85 3 4 82 83 66 66 |