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Tax Year
Written Affirmation for
2016
15951601020000
WC
an Oregon Real Property Conveyance
Form
Social Security number (SSN)/FEIN of transferor
Transferor first name, middle initial, and last name
Transferor is (check one)
Individual
C corporation
Transferor spouse first name, middle initial, and last name
Spouse Social Security number (SSN)
Transferor’s address
City
State
ZIP code
Percentage of ownership interest in property
Date acquired
Transferor’s daytime phone
(
)
/
/
Address of property conveyed
Type of property conveyed:
Specially assessed
Undeveloped land
Acquired as gift
Rental property
Farm use
Other: __________________________________________________________________
Part A: Exemption
I (we) hereby affirm that I am (we are) the transferor(s) of the property described above, and that as of the date of closing, I have (we have)
knowledge (or have received advice from a tax professional) that there is no tax likely to be due under Oregon Revised Statutes (ORS)
Chapters 118, 316, 317, or 318. Enter explanation and calculation below, or attach separate page.
Part B: Calculation of gain and tax payment
(see FAQs on page 5 for assistance on calculation)
Use this section to calculate Oregon tax required to be withheld. The tax payment sent to the Oregon Department of Revenue by the
authorized agent will be credited to the Oregon income tax account of the transferor as an estimated payment.
1. Consideration. Amount of seller’s share of sales price .................................................................................... 1
2. Multiply line 1 by 4% (0.04) .............................................................................................. 2
3. Net proceeds. (“cash to seller”) ...................................................................................... 3
4. Your federal or Oregon adjusted basis in the property, whichever is greater
(attach separate basis calculation) ..................................................................................................................... 4
5. Selling costs directly related to this conveyance not already included in the basis calculation ........................ 5
6. Add lines 4 and 5 ............................................................................................................................................... 6
7. Taxable gain. Subtract line 6 from line 1 ........................................................................................................... 7
8. Reduce gain by applicable nonrecognition section under federal law. Enter IRC section ________ ................. 8
9. Subtract line 8 from line 7 .................................................................................................................................. 9
10. Multiply line 9 by 8% (0.08) ............................................................................................ 10
11. Tax payment. Enter the least of lines 2, 3, or 10 ............................................................................................. 11 $
I (we) certify under penalty of perjury the above statements are true. I (we) understand that the amount shown on line 11 is being remit-
ted. If the amount on line 11 is zero, no tax payment is being made. [Corporate officers, fiduciaries, or other qualified persons signing on
behalf of the taxpayer(s): By signing, I also certify that I have the authority to execute this form.]
Signed under penalty of perjury:
Transferor’s signature
Date
X
/
/
Spouse’s signature (if applicable)
Date
X
/
/
KEEP A COPY OF THIS FORM IN AUTHORIZED AGENT’S RECORDS FOR SIX YEARS FROM DATE SIGNED
Mail within 30 days of closing to:
Oregon Department of Revenue, ATTN: Processing Center, 955 Center St NE, Salem OR 97301
150-101-183 (Rev. 12-15)