Form Or-20-Ins - Oregon Insurance Excise Tax Return - 2016 Page 3
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42016 Form OR‑20‑INS
02931601030000
Page 3 of 3, 150-102-129 (Rev. 10-16)
Oregon Department of Revenue
Schedule ES—Estimated Tax Payments or Other Prepayments
Name of payer
1.
Quarter 1
•
Payer’s FEIN
Date paid
•
.00
–
/
/
Amount paid .....................................
1.
Name of payer
2.
Quarter 2
•
Payer’s FEIN
Date paid
•
.00
–
/
/
Amount paid .....................................
2.
Name of payer
3.
Quarter 3
•
Payer’s FEIN
Date paid
•
.00
–
/
/
Amount paid .....................................
3.
Name of payer
4.
Quarter 4
•
Payer’s FEIN
Date paid
•
.00
–
/
/
Amount paid .....................................
4.
.00
•
5. Overpayment of another year’s tax applied as a credit against this year’s tax ................................................
5.
.00
/
/
6. Payments made with extension or other prepayments for this tax year and date paid _____________________ 6.
.00
7. Claim of right credit (include computation and explanation) ................................................................................ 7.
.00
8. Total prepayments (carry to line 26 on previous page)......................................................................................... 8.
Under penalty of false swearing, I declare that the information in this return and any enclosures is true, correct, and complete.
Signature of officer
Signature of preparer other than taxpayer
License number of preparer
Sign
•
X
X
Here
Date
Date
Phone number
(
)
–
/
/
/
/
Print name of officer
Print name of preparer
Title of officer
Address of preparer
Mail refund returns and no tax due returns to: Mail tax‑to‑pay returns with payment and payment voucher to:
Refund, PO Box 14777, Salem OR 97309-0960
Oregon Department of Revenue, PO Box 14790, Salem OR 97309-0470
Include Oregon schedules and file with the Oregon Department of Revenue.
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