- 2 -
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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 2 84 85
3 4 82 83
3 3
4 4
5 Form OR‑OC‑TR 5
6 Page 2 of 2, 150-101-158 Oregon Department of Revenue 18530001020000 6
7 (Rev. 09-08-22, ver. 01) 7
8 8
9 Payment amount to remain on PTE account. 9
10 Payment 1 Payment 2 Payment 3 Payment 4 10
11 11
99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00
12 12
13 Total for PTE 13
14 14
99,999,999,999.00.00
15 15
16 1. Owner first name Initial Last name SSN Owner type 16
17 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – XXXXXXXXXXXXXX 17
18 Entity name FEIN 18
19 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 19
20 Address City State ZIP code 20
21 21
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
22 (a) Payment 1 (b) Payment 2 (c) Payment 3 (d) Payment 4 22
23 23
99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00
24 24
25 Total for owner 25
26 26
99,999,999,999.00.00
27 27
28 28
29 2. Owner first name Initial Last name SSN Owner type 29
30 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – XXXXXXXXXXXXXX 30
31 Entity name FEIN 31
32 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 32
33 Address City State ZIP code 33
34 34
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
35 (a) Payment 1 (b) Payment 2 (c) Payment 3 (d) Payment 4 35
36 36
99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00
37 37
38 Total for owner 38
39 39
99,999,999,999.00.00
40 40
41 41
42 3. Owner first name Initial Last name SSN Owner type 42
43 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – XXXXXXXXXXXXXX 43
44 Entity name FEIN 44
45 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 45
46 Address City State ZIP code 46
47 47
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
48 (a) Payment 1 (b) Payment 2 (c) Payment 3 (d) Payment 4 48
49 49
99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00 99,999,999,999.00.00
50 50
51 Total for owner 51
52 52
99,999,999,999.00.00
53 53
54 54
55 Total payments to remain on account and to transfer to owners (must match estimated payments 1–4 on page 1 of Form OR-OC-TR). 55
56 56
57 4. (a) Total of payment 1 (b) Total of payment 2 (c) Total of payment 3 (d) Total of payment 4 57
58 58
99,999,999,999.00.0099,999,999,999.00.00 99,999,999,999.00.0099,999,999,999.00.00
59 59
60 60
61 61
62 62
63 Page _________999of _________999 63
64 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
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