Form 150-211-054 - Registration Report
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1FOR AGENCY USE ONLY
REGISTRATION REPORT
BIN
Date received
Withholding on IRAs,
Annuities, and Compensation Plans
E/R code
County
SIC
NAICS
525110
• Be sure to read the instructions below.
• We cannot issue a Business Identification Number (BIN) if your registration is incomplete.
• You must fill in the date of first disbursement.
• Please type or print. Press hard if printing.
Business name
Type of ownership
Pension and Annuity
Date of disbursement
(this box must be completed)
WITHHOLDING
Federal ID number
Business telephone number
TAX
Month _______ Day _______ Year_______
(
)
Ext.
Person at business authorized to discuss your acount with us
Telephone number
E-mail address
(
)
Ext.
Business mailing address
City
State
ZIP code
Offsite payroll service, accountant, or bookkeeper
Contact person at the offsite payroll service, accountant, or bookkeeper
Telephone number
E-mail address
(
)
Ext.
Mailing address for offsite payroll service (send:
forms
billings to this address?)
C/O
City
State
ZIP code
Bank reference/branch address
IDENTIFICATION OF OWNERS, PARTNERS, CORPORATE OFFICERS, ETC.
(List additional owners on a separate sheet and attach to this form)
Social Security number
Telephone number
Social Security number
Telephone number
(
)
(
)
Name
Name
Home address
Home address
City
State
ZIP code
City
State
ZIP code
Responsible for:
Responsible for:
Filing tax returns
Paying taxes
Filing tax returns
Paying taxes
Determining which creditors to pay first
Determining which creditors to pay first
AUTHORIZATION
I certify the above statements to be true and correct. I authorize the Department of Revenue to verify any of the above information with regard to this
business. I will notify the Department of Revenue if there is a change or cancellation of the above authorized representative.
Signature
Date
Signature
Date
X
X
INSTRUCTIONS
Who must register
Forms to be filed
Payors of any IRAs, annuities, or compensation plan distribu-
OQ—Oregon Quarterly Combined Tax Report (fill out column B
tions to an individual.
only on the OQ)
Need more information? Call 503-945-8091.
WR—Oregon Annual Reconciliation Report
150-211-054 (4-01) Web
OREGON DEPARTMENT OF REVENUE
Mail white and yellow copies to:
PO BOX 14800
Retain pink copy for your records.
SALEM OR 97309-0920
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