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Oregon Department of Revenue
5 Form OR-STI-V 5
6 Oregon Statewide Transit Individual 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 begins (MM/DD/YYYY) Tax year ends (MM/DD/YYYY) 9
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11 99/99/9999/ / 99/99/9999/ / 11
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13 First name Initial 13
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XXXXXXXXXXXXXXXX X
16 Last name 16
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19 Social Security number (SSN) Date of birth (MM/DD/YYYY) 19
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21 999-99-9999 99/99/9999/ / 21
22 Current mailing address 22
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
25 City State ZIP code 25
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XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
28 Phone 28
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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. X Original return or extension 48
49 Use this voucher only if you are sending a payment separate from a return. For 49
50 more information, see Form OR-STI-V Instructions. Make your check, money order, Amended return 50
51 or cashier’s check payable to the Oregon Department of Revenue. Write “Form X 51
OR-STI-V,” your daytime phone, the last four digits of your SSN or ITIN, and the tax
52 year on your payment. Don’t mail cash. Mail the payment and voucher to: 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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59 150-101-072 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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