Clear Form
REGISTRATION REPORT
FOR AGENCY USE ONLY
BIN
Date received
Withholding on IRAs,
Annuities, and Compensation Plans
E/R code
County
SIC
NAICS
525110
• Bold print are required fields.
• We cannot issue a business identification number (BIN) if your registrationis incomplete.
• You must fill in the date of first disbursement.
• Please type or print.
• Note: Use the Combined Employers Registration form 150-211-055 if you need to establish a payroll account.
Business name
Type of ownership
Pension and Annuity
Date of disbursement (this box must be completed)
Month ________ Day ________ Year ________
WITHHOLDING
TAX
One-time distribution?
Business telephone number
Federal identification number (FEIN)
( )
Yes
No
Ext.
Person at business authorized to discuss your account with us
Telephone number
E-mail address
( )
Ext.
Business mailing address
FAX number
( )
City
State
ZIP code
Offsite payroll service, accountant, or bookkeeper
Contact person at the offsite payroll service, accountant, or bookkeeper Telephone number
E-mail address
( )
Ext.
Mailing address for offsite payroll service (send:
forms
billings to this address?)
C/O
City
State
ZIP code
Bank reference / branch address
IDENTIFICATION OF OWNERS, PARTNERS, CORPORATE OFFICERS, ETC.
(list additional owners on a separate sheet and attach to this form)
Social Security number*
Telephone number
Social Security number*
Telephone number
( )
( )
Name
Name
Home address
Home address
City
State
ZIP code
City
State
ZIP code
Responsible for:
Responsible for:
Filing tax returns
Paying taxes
Filing tax returns
Paying taxes
Determining which creditors to pay first
Determining which creditors to pay first
AUTHORIZATION
I certify the above statements to be true and correct. I authorize the Department of Revenue to verify any of the above information with regard to this
business. I will notify the Department of Revenue if there is a change or cancellation of the above authorized representative.
Signature
Date
Signature
Date
X
X
INSTRUCTIONS
Who must register
Forms to be filed
OQ— Oregon Quarterly Combined Tax Report (fill out column B
Payors of any IRAs, annuities, or compensation plan distributions
to an individual.
only on the OQ)
Need more information? Call 503-945-8091.
WR— O regon Annual Reconciliation Report
*As required by OAR 150-305.100.
Fax to: 503-947-1528 or Mail to: OREGON EMPLOYMENT DEPARTMENT
875 UNION ST NE RM 107
SALEM OR 97311
Retain a copy for your records.
150-211-054 (Rev. 03-12)
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