Form Oa - Domestic Oregon Annual Tax Report - 2000
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1FORM OA – DOMESTIC - 2000
BUSINESS NAME
OREGON ANNUAL TAX REPORT
:
Business
Identification Number
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Standard Industrial
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Federal EIN
Classification Code
If mailing address, name or Federal EIN is wrong, complete
“Change in Status Report” found in the instruction booklet.
Using 4th quarter totals, report the number
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of workers covered for Unemployment insurance
who worked during or received pay for the
period which includes the 12th of the month.
(see instruction booklet)
Place a -0- in “subject wages” box of a program for which employer is subject, but there was no payroll this year.
UNEMPLOYMENT INSURANCE
UNEMPLOYMENT INSURANCE
UNEMPLOYMENT INSURANCE
UNEMPLOYMENT INSURANCE
STATE WITHHOLDING
STATE WITHHOLDING
STATE WITHHOLDING
STATE WITHHOLDING
Column A
Column B
1.
1.
1.
1.
Subject
Subject
Subject
Subject wages .
wages .
wages .
wages .
.
.
.
.
.
.
.
.
1.
1.
1.
1.
Subject
Subject
Subject
Subject wages .
wages .
wages .
wages .
.
.
.
.
.
.
.
.
2.
2.
2.
2.
Excess
Excess wages
wages
.
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.
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.
Excess
Excess
wages
wages
.
.
.
.
.
.
(See instruction booklet)
3.
3.
3.
3.
Taxable
Taxable
Taxable
Taxable wages .
wages .
wages .
wages .
.
.
.
.
.
.
.
.
(Box 1A minus Box 2A)
4.
4.
4.
4.
Tax rate.
Tax rate.
Tax rate.
Tax rate.
.
.
.
.
.
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5.
5.
5.
5.
5.
5.
5.
5.
Tax
Tax
.
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.
.
.
.
.
.
.
Tax .
Tax .
.
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.
Tax
Tax
.
.
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.
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Tax .
Tax .
.
.
.
.
.
.
.
.
.
.
.
.
(Box 3A times Box 4A)
(Must enter tax for year)
6.
6.
6.
6.
Less: Oregon Tax prepaid
Less: Oregon Tax prepaid
Less: Oregon Tax prepaid
Less: Oregon Tax prepaid
6.
6.
6.
6.
Less: Oregon Tax prepaid
Less: Oregon Tax prepaid
Less: Oregon Tax prepaid
Less: Oregon Tax prepaid
7.
7.
7.
7.
Plus: UI penalty and
Plus: UI penalty and
Plus: UI penalty and
Plus: UI penalty and
interest owed . .
interest owed . .
interest owed . .
interest owed . .
8.
8.
8.
8.
8.
8.
8.
8.
Total Tax
Total Tax Due .
Due .
.
.
. . . .
Total Tax Due.
Total Tax Due.
.
.
.
.
.
.
Total Tax
Total Tax
Due .
Due .
.
.
. . . .
Total Tax Due.
Total Tax Due.
.
.
.
.
.
.
(Box 5A less Box 6A plus Box 7A)
(Box 5B less Box 6B)
WORKERS’ BENEFIT FUND
WORKERS’ BENEFIT FUND
WORKERS’ BENEFIT FUND
WORKERS’ BENEFIT FUND
Put –0- in Boxes 9 & 11 if
there were no subject hours
(WBF) ASSESSMENT
(WBF) ASSESSMENT
(WBF) ASSESSMENT
(WBF) ASSESSMENT
worked in the year.
14. TOTAL PAYMENT DUE
TOTAL PAYMENT DUE
TOTAL PAYMENT DUE
TOTAL PAYMENT DUE
9 9 9 9
. . . .
Number of hours worked
Number of hours worked
Number of hours worked
Number of hours worked
9 9 9 9
. . . .
Add Boxes 8A, 8B, and 13.
Make checks payable to
10.
10.
10.
10.
WBF assessment rate
WBF assessment rate
WBF assessment rate
WBF assessment rate
“Oregon Department of Revenue.”
Only add amounts due.
Do not add credits in one
11.
11.
11.
11.
Total assessment
Total assessment
Total assessment
Total assessment
program to offset taxes owed in another program
(Box 9 times Box 10)
(Box 9 times Box 10)
(Box 9 times Box 10)
(Box 9 times Box 10)
Include payment coupon (Form OTC)
Include payment coupon (Form OTC)
Include payment coupon (Form OTC)
Include payment coupon (Form OTC)
1 1 1 1
1 1 1 1
2 2 2 2
2 2 2 2
. . . .
. . . .
Less: Assessment prepaid
Less: Assessment prepaid
Less: Assessment prepaid
Less: Assessment prepaid
13.
13.
Total Assessment Due
Total Assessment Due
13.
13.
Total Assessment Due
Total Assessment Due
NOTE:
NOTE:
NOTE:
NOTE:
This assessment is separate from your
This assessment is separate from your
This assessment is separate from your
This assessment is separate from your
workers’ compensation insurance premium.
workers’ compensation insurance premium.
workers’ compensation insurance premium.
workers’ compensation insurance premium.
I certify this report is true and correct and is filed under penalty of false swearing.
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Signature
X
(
)
(
)
Required
MAIL TO:
OREGON DEPARTMENT OF REVENUE: PO BOX 14800, SALEM, OR
97309-0920
150-211-156 (REV 10-00)
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