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Form OQ/OA Amended
Oregon Amended Payroll Tax Report
6522010123
Fax to: 503-947-1700 Mail to: Oregon Department of Revenue, PO Box 14800, Salem OR 97309-0920 Date received
To pay: Complete Form OR-OTC-V and mail with your check, payable to Oregon Department of Revenue
Business name Do not submit photocopies.
Federal employer identification number (FEIN) Business identification number (BIN) Quarter/Year (Q/YY) changed
/
Reason for amending
Corrected Amount Original Reported Amount Net Change
State Withholding
1. Subject wages...................
2. Total tax amount................
3. Tax pre-paid this quarter ...
4. Total due ............................
Statewide Transit
5. Subject wages...................
6. Total tax amount................
7. Tax pre-paid this quarter ...
8. Total due ............................
TriMet
9. Subject wages...................
10. Total tax amount................
11. Tax pre-paid this quarter ...
12. Total due ............................
Lane Transit District (LTD)
13. Subject wages...................
14. Total tax amount................
15. Tax pre-paid this quarter ...
16. Total due ............................
17a. Corrected First Month 17b. Corrected Second Month 17c. Corrected Third Month
Monthly Summary of State
Withholding Tax Liability
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150-206-522 (Rev. 08-18-22) Page 1 of 2
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