Form Or-18 - Report Of Tax Payments On Real Property Conveyances Page 6

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Fill in Tax Year

Form

Written Affirmation for

an Oregon Real Property Conveyance

Name(s) of individual or C corporation transferring property (transferor)

Transferor is (check one)

Individual

C corporation

Transferor’s address

City

State

ZIP code

Transferor’s Social Security number (SSN)/BIN

Transferor’s federal employer identification number (FEIN)

Percentage of ownership interest in property

Date acquired

Transferor’s daytime telephone number

(

)

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

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

Spouse’s/RDP’s signature (if applicable)

Date

KEEP THIS FORM IN AUTHORIZED AGENT’S RECORDS FOR SIX YEARS FROM DATE SIGNED

Mail to: Oregon Department of Revenue, 955 Center St NE, Salem OR 97301

150-101-183 (Rev. 12-12)