Oregon Pass-Through Entity Owner Payments

Pass-Through Entity Owner Payments
2021 Form OR-19, Annual Report of Nonresident Owner Tax Payments, 150-101-182
Clear form

2021 Form OR-19

Office use only

15772101010000

Oregon Department of Revenue

Page 1 of 2, 150-101-182
(Rev. 10-08-21, ver. 01)

Annual Report of Nonresident Owner Tax Payments
Submit original form—do not submit photocopy.
Pass-through entity (PTE) name

Federal employer identification number (FEIN)

PTE address

City

Contact phone

–
Preparer first name (see instructions)

Initial

–

–
State

Last name

ZIP code

Preparer contact phone

–

–
Section 1
Type of entity:

Partnership

S corporation

Estimated payments

LLC

LLP

LP

Trust

Payment date
(MM/DD/YYYY)

Amount of payment

Payment 1

.00

/

/

Payment 2

.00

/

/

Payment 3

.00

/

/

Payment 4

.00

/

/

Important—Complete page 2 before signing and mailing form.

Sign below and keep a copy of this return for your tax records.
Under penalties for false swearing, I certify that I am authorized to request transfer of estimated tax payments from the abovenamed pass-through entity’s tax account to the tax accounts listed on this form.
Title

Signature of general partner, LLC member, or officer

X

Print first name of general partner, LLC member, or officer

Initial

Last name

Date

Paid preparer’s first name

Initial

Last name

Date

Signature of paid preparer

X

/
Preparer address

/

/
/

City

State

Preparer license number

Phone

ZIP code

Submit this form online at www.oregon.gov/dor or mail to:	
Oregon Department of Revenue
PO Box 14950
Salem OR 97309-0950

–

This form is due on the last day of the second month after the end of the entity’s tax year.
The due date for entities using a calendar 2021 tax year is February 28, 2022.

–

2021 Form OR-19
15772101020000

Oregon Department of Revenue

Page 2 of 2, 150-101-182
(Rev. 10-08-21, ver. 01)

Section 2­—Submit additional copies of this form when reporting for more than four owners
(1) Owner first name

Initial

Last name

Social Security number (SSN)

–
Entity name

Owner type

–
FEIN

–
Address

City

(a) Payment 1

.00

(b) Payment 2

State

(c) Payment 3

.00

ZIP code

(d) Payment 4

.00

Total for owner

(2) Owner first name

Initial

Last name

.00
.00

Owner type

SSN

–
Entity name

–
FEIN

–
Address

City

(a) Payment 1

.00

(b) Payment 2

State

(c) Payment 3

.00

ZIP code

(d) Payment 4

.00

Total for owner

(3) Owner first name

Initial

Last name

.00
.00

Owner type

SSN

–
Entity name

–
FEIN

–
Address

City

(a) Payment 1

.00

(b) Payment 2

State

(c) Payment 3

.00

ZIP code

(d) Payment 4

.00

Total for owner

(4) Owner first name

Initial

Last name

.00

Owner type

SSN

–
Entity name

.00

–
FEIN

–
Address

City

(a) Payment 1

.00

(b) Payment 2

.00

State

(c) Payment 3

.00

ZIP code

(d) Payment 4

Total for owner

.00
.00

Total payments to transfer to owners. If multiple pages, enter on last page only. These amounts must match estimated payments 1–4 on
page 1.
(a) Total of payment 1

.00

(b) Total of payment 2

.00

(c) Total of payment 3

.00

(d) Total of payment 4

.00

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