Clear Form
Oregon Affidavit
for a Nonresident Owner
For office use only
in a Pass-Through Entity
Date received
Beginning with tax year:
Nonresident owner information
Name of nonresident owner
Social Security no. or federal employer identification no. (FEIN)
Street or mailing address
Oregon business identification no. (BIN) (if applicable)
City
State
ZIP code
Telephone number
(
)
Ownership percentage
Estimated Oregon-source distributive income each year
%
$
Pass-through entity information
Name of pass-through entity (PTE)
FEIN
Street or mailing address
BIN
City
State
ZIP code
Telephone number
(
)
This form must be filed every time any of the nonresident owner or pass-through entity information entered above changes.
Agreement to file
I agree to timely file all required Oregon income or excise tax return(s) and to make timely payments of all taxes imposed
by the state of Oregon with respect to my share of the Oregon income of the pass-through entity named above. I
understand that I am subject to the jurisdiction of the state of Oregon for purposes of the collection of unpaid income
tax, together with related penalties and interest.
Signature
Taxpayer’s or authorized agent’s signature
Date
X
Revocation of this affidavit
By signing below, I declare that:
I am an Oregon resident;
I am subject to withholding on the income from the above-listed PTE;
I am no longer an owner in the above-listed PTE; or
I am joining in the filing of an Oregon Composite Return.
Signature
Taxpayer’s or authorized agent’s signature
Date
X
Mail to:
Oregon Department of Revenue
PTAC Compliance
955 Center St NE
Salem OR 97301-2555
150-101-175 (Rev. 12-08)