Settlement Offer Application Form - Oregon Department Of Revenue Page 7
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Department use only
Date received
Settlement Offer Application
Revenue agent
• Complete all sections. • Don’t fill in shaded boxes.
Section 1. Personal information
Your first name
MI
Last name
Your Social Security number
Your date of birth
–
–
Other names or aliases used
Spouse/RDP first name
MI
Last name
Spouse/RDP Social Security number
Spouse/RDP date of birth
–
–
Spouse/RDP other names or aliases used
Your driver’s license number
State
Spouse/RDP driver’s license number
State
Social Security number
Relationship
Dependent name (living with you)
Date of birth
–
–
Dependent name (living with you)
Social Security number
Date of birth
Relationship
–
–
Social Security number
Relationship
Dependent name (living with you)
Date of birth
–
–
Phone number
Your current street address
City
State
ZIP code
County
(
)
Your mailing address (if different from above)
City
State
ZIP code
E-mail address
Name of your tax representative (CPA, attorney, etc)
Fax number
Phone number
(
)
(
)
Tax representative’s address
City
State
ZIP code
Section 2. Employment information
Name of employer or business (if self-employed)
Phone number
(
)
Address
City
State
ZIP code
How long employed:_____
_____
Occupation: __________________
Wage earner
Sole proprietor
Partner
Owner/officer
Year(s)
Month(s)
Paid:
Weekly
Every 2 weeks
Monthly
Twice monthly (e.g., 1st & 15th)
Number of allowances claimed on Form W-4:________
Phone number
Name of spouse/RDP employer or business (if self-employed)
(
)
City
State
ZIP code
Address
How long employed:_____
_____
Occupation: __________________
Wage earner
Sole proprietor
Partner
Owner/officer
Year(s)
Month(s)
Paid:
Weekly
Every 2 weeks
Monthly
Twice monthly (e.g., 1st & 15th)
Number of allowances claimed on Form W-4:________
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