Clear Form
OREGON AFFIDAVIT
FOR A NONRESIDENT OWNER
For Office Use Only
IN A PASS-THROUGH ENTITY
Date Received
Beginning with tax year: _________________
NONRESIDENT OWNER INFORMATION
Name of Nonresident Owner
Social Security No. or Federal Employer Identification No.
Street or Mailing Address
Oregon Business Identification No. (if applicable)
City
State
ZIP Code
Telephone Number
(
)
Ownership Percentage
Estimated Oregon-Source Distributive Income Each Year
%
$
PASS-THROUGH ENTITY INFORMATION
Name of Pass-Through Entity (PTE)
Federal Employer Identification Number
Street or Mailing Address
Oregon Business Identification Number
City
State
ZIP Code
Telephone Number
(
)
This form must be filed every time a change occurs.
AGREEMENT TO FILE
I agree to timely file all required Oregon income or excise tax return(s) and to make timely payments of all taxes imposed
by the state of Oregon with respect to my share of the Oregon income of the pass-through entity named above. I
understand that I am subject to the jurisdiction of the state of Oregon for purposes of the collection of unpaid income
tax, together with related penalties and interest.
SIGNATURE
Taxpayer’s or Authorized Agent’s Signature
Date
X
REVOCATION
By signing below, I also agree to the following:
I am subject to withholding on the
I am no longer an owner in the
I am joining in the filing of an
income from the above-listed PTE;
above-listed PTE; or
Oregon Composite Return.
SIGNATURE
Taxpayer’s or Authorized Agent’s Signature
Date
X
Mail to:
OREGON DEPARTMENT OF REVENUE
PTAC COMPLIANCE
955 CENTER ST NE
SALEM OR 97301-2555
150-101-175 (12-07) Web