Form Ltd And Instructions Draft - Self-Employment Tax - 2011 Page 5
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FORM
2011
Lane County
LTD
Date received
•
Mass Transit District
•
•
Payment
•
(240)
Self-Employment Tax
1
2
3
•
•
•
/
/
/
/
If you have previously
Name change
Fiscal Year
Fiscal Year
Mo
Day
Year
Mo
Day
Year
•
•
11
filed a return, indicate if:
Address change
Beginning:
Ending:
Last name (if an individual filing)
First name and initial
Social Security number (SSN)
•
•
–
–
Partnership name (if a partnership filing)
Federal employer identification number (FEIN)
Business address
Oregon business identification number (BIN)
•
City
State
ZIP Code
County
Telephone number
(
)
•
Did you file Form LTD for 2010?
An extension has been filed
•
Yes
This is an amended return
•
No (if No, give reason) _______________________________________________________
Utility or telecommunications
Include your payment with this return.
Round all amounts to the nearest whole dollar.
•
1. Self-employment earnings from federal Schedule SE or Partnership Form 1065 ................................
1
%
2. Apportionment percentage .........................................................................................................................2
•
3. Net self-employment earnings. Multiply line 1 by line 2 ........................................................................
3
•
4. Less: Exclusion. Not more than $400 per taxpayer ..............................................................................
4
•
5. Net earnings subject to transit district tax. Line 3 minus line 4 ............................................................
5
•
6. Net tax. Multiply line 5 by 0.0067 ..........................................................................................................
6
•
7. Prepayments .........................................................................................................................................
7
•
8. TAX TO PAY. Is line 6 more than line 7? If so, line 6 minus line 7 .....................................TAX TO PAY
8
9. Penalty and interest for filing or paying late ................................................................................................9
10. Total amount due. Line 8 plus line 9. .........................................................................................................10
•
11. REFUND. Is line 7 more than line 6? If so, line 7 minus line 6 ............................................... REFUND 11
Individuals: Attach a copy of your federal Schedule SE. Business Activity:
Sales
Services
Other: ____________________
Partnerships: Attach a schedule listing each partner’s name, Social Security number, partnership earnings, and exclusion.
Apportioning? Attach a copy of TSE-AP.
Under penalty of false swearing, I declare that the information in this return and any attachments is
I authorize the Department
true, correct, and complete.
of Revenue to discuss this
return with this preparer.
Yes
No
Your signature
Date
Signature of preparer other than taxpayer
License No.
•
X
X
SIGN
HERE
Telephone No.
Address
Do NOT attach your LTD self-employment tax return to your Oregon income tax return, or any other form.
Make check or money order payable to:
Mail your return to: LTDSE, Oregon Department of Revenue
Oregon Department of Revenue
PO Box 14003, Salem OR 97309-2502
150-560-001 (Rev. 12-11)
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