Form 40es - Oregon Individual Estimated Tax - 2004

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For Department Use Only
For Tax Year
Form
Oregon Individual Estimated Tax
4
4th
Date Received
2004
40ES
January 18, 2005
Quarter
Due by:
See instructions on the back.
First four letters of your last name
Social Security number
Enter Payment Amount
Spouse’s Social Security number
First four letters of spouse’s last name
$
0 0
Last name, first name, and initial
Spouse’s last name, first name, and initial (if joint payment)
Mailing address
Check if new address
City
State
ZIP code
Telephone number
(
)
150-101-026-2 (Rev. 12-03)
For Department Use Only
For Tax Year
Form
Oregon Individual Estimated Tax
3
3rd
Date Received
2004
40ES
September 15, 2004
Quarter
Due by:
See instructions on the back.
Social Security number
First four letters of your last name
Enter Payment Amount
Spouse’s Social Security number
First four letters of spouse’s last name
$
0 0
Last name, first name, and initial
Spouse’s last name, first name, and initial (if joint payment)
Mailing address
Check if new address
City
State
ZIP code
Telephone number
(
)
150-101-026-2 (Rev. 12-03)
For Department Use Only
For Tax Year
Form
Oregon Individual Estimated Tax
2
2nd
Date Received
2004
40ES
June 15, 2004
Quarter
Due by:
See instructions on the back.
Social Security number
First four letters of your last name
Enter Payment Amount
Spouse’s Social Security number
First four letters of spouse’s last name
$
0 0
Last name, first name, and initial
Spouse’s last name, first name, and initial (if joint payment)
Mailing address
Check if new address
City
State
ZIP code
Telephone number
(
)
150-101-026-2 (Rev. 12-03)
For Department Use Only
For Tax Year
Form
Oregon Individual Estimated Tax
1
1st
Date Received
2004
40ES
April 15, 2004
Quarter
Due by:
See instructions on the back.
Social Security number
First four letters of your last name
Enter Payment Amount
Spouse’s Social Security number
First four letters of spouse’s last name
$
0 0
Last name, first name, and initial
Spouse’s last name, first name, and initial (if joint payment)
Mailing address
Check if new address
City
Telephone number
State
ZIP code
(
)
150-101-026-2 (Rev. 12-03)

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