Form Rpc - Personal Income Tax Return Payment Coupon - 2003
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1Fill out the coupon below and send in with your payment and tax return.
Mail tax-to-pay returns to:
Oregon Department of Revenue
PO Box 14555
Salem OR 97309-0940
Clear form
Please cut along the dotted line.
2003
Personal Income Tax Return Payment Coupon
Form
For Department Use Only
RPC
Date Received
OREGON DEPARTMENT OF REVENUE
Due by April 15, 2004
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
$
Please fill in all applicable boxes below.
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
(
)
150-101-164 (Rev. 12-03) Web
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Parent category: Financial