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 IMPORTANT! THIS FORM MUST BE FILED ELECTRONICALLY. Form All layers With grid &2 data 84 85
3 4 82 83
3 A PRINTABLE COPY MAY BE PROVIDED FOR THE 3
4 CUSTOMER'S RECORDS ONLY. 4
5 Oregon Department of Revenue 5
2022 Form OR-21
6 Oregon Pass-through Entity Elective Tax Return 6
7 7
8 8
9 Page 1 of 4 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. 9
10 Tax year beginning (MM/DD/YYYY) Tax year ending (MM/DD/YYYY) 10
11 11
12 99/99/9999/ / 99/99/9999/ / 12
13 13
14 Part A: Pass-through entity (PTE) information 14
15 PTE legal name 15
16 16
17 17
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
18 Doing business as (DBA) or assumed business name (ABN), if any 18
19 19
20 20
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
21 Current address 21
22 22
23 23
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
24 City State ZIP code 24
25 25
26 XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX - 26
27 Federal employer identification number (FEIN) Entity type: 27
28 28
29 99-9999999 X Partnership X S corporation 29
30 30
31 Contact first name Initial 31
32 32
33 33
XXXXXXXXXXXXXXXX X
34 Contact last name 34
35 35
36 36
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
37 Contact phone 37
38 38
39 39
999-999-9999
40 Email 40
41 41
42 42
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
43 43
44 Part B: Checkboxes 44
45 45
46 1. Election. The pass-through entity (PTE) elects to be liable for and pay the Oregon PTE elective tax 46
47 (PTE-E tax). By checking this box, I declare: (a) under penalty of false swearing that, as of the date 47
48 this return is submitted, all members of the PTE elect to be liable for and pay the PTE-E tax or (b) 48
49 under penalty of perjury that I am an officer, manager, or member of the PTE with the authority to 49
50 make this election on behalf of all members of the PTE. 1. X Election 50
51 51
52 2. Revocation. The PTE revokes a prior election. By checking this box, I declare under penalty of false 52
53 swearing that the PTE revokes a prior election to be liable for and pay the PTE-E tax, and that the 53
54 PTE requests a refund of all PTE-E tax payments made by the PTE or by any of its members on the 54
55 PTE’s behalf. 2. X Revocation 55
56 56
57 3. Amended. The PTE is filing this return to make corrections to a prior PTE-E tax return. 3. X Amended 57
58 58
59 4. Extension. The PTE has requested an extension of time to file this return. 4. X Extension 59
60 Continued on next page 60
61 61
62 62
150-107-114
63 (Rev. 09-13-22, ver. 01) 22402201010000 63
64 64
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