Form 40p - Oregon Individual Income Tax Return For Part-Year Residents - 2015 Page 4

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2015 Form 40P
Name
SSN
00611501040000
Sign here—Under penalty of false swearing, I declare that the information in this return is true, correct, and complete.
Your signature
Date
X
Spouse’s signature (if filing jointly, both must sign)
Date
X
•
Signature of preparer other than taxpayer
Preparer license no.
Preparer phone
X
Preparer address
City
State
ZIP code
If you owe, make your check or money order payable to the Oregon Department of Revenue. Write your daytime phone number and
“2015 Oregon Form 40P” on your check or money order. Include your payment, along with the payment voucher, with this return.
— Mail tax-due returns to: Oregon Department of Revenue, PO Box 14555, Salem OR 97309-0940.
— Mail refund and no-tax-due returns to: Refund, PO Box 14700, Salem OR 97309-0930.
Important: Include a copy of your federal Form 1040, 1040A, 1040EZ, 1040NR, or 1040NR-EZ.
Amended Statement
Explanation of adjustments
If this is an amended return, complete this statement with an explanation of what you are amending.
Indicate the return line numbers and the reason for each change. If your filing status has changed, explain why.
Page 4
150-101-055 (Rev. 12-15)

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