Pass-Through Entity Owner Payments And Oregon Affidavit - 2015 Page 5

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Annual Report of Nonresident Owner Tax Payments
Form
OR-19
2015
Entity tax year end date
Pass-through entity information
Pass-through entity (PTE) name
PTE FEIN
Check date
Estimated payments
Amount of payment
(MM/DD/YYYY)
PTE address
PTE BIN
Payment 1
.00
City
State
ZIP code
Contact phone
Payment 2
.00
Name of contact person
Payment 3
.00
Partnership
S Corporation
LLC
LLP
LP
Payment 4
Type of entity:
.00
FEIN/SSN
Name and address
Owner type
Payment 1
Payment 2
Payment 3
Payment 4
Total for
(a)
(b)
(c)
(d)
(e)
(f)
(g)
owner (h)
1.
$
.00 $
.00 $
.00 $
.00 $
.00
2.
$
.00 $
.00 $
.00 $
.00 $
.00
3.
$
.00 $
.00 $
.00 $
.00 $
.00
4.
$
.00 $
.00 $
.00 $
.00 $
.00
5.
$
.00 $
.00 $
.00 $
.00 $
.00
6.
$
.00 $
.00 $
.00 $
.00 $
.00
7.
$
.00 $
.00 $
.00 $
.00 $
.00
Total payments
(Enter on last page only. Must match payments 1–4 listed above.)
$
.00 $
.00 $
.00 $
.00
Page
of
Mail this form to: Oregon Department of Revenue, P.O. Box 14950 Salem, OR 97309-0950
This form is due by the end of the second month after the end of the entity’s tax year. The due date for entities using a calendar 2015 tax year is February 29, 2016.
150-101-182 (Rev. 12-14)

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