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5           Form OR-EF                                                                                                                                 Office use only 5
6           Page 1 of 2, 150-101-339                        Oregon Department of Revenue 01610001010000                                                                6
7           (Rev. 08-19-22, ver. 01)                                                                                                                                   7
8           Oregon Individual Income Tax Declaration for Electronic Filing                                                                                             8
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12                                                                                                                                                     Tax year        12
13              Don’t mail this form to the                                                                                                                            13
14          Oregon Department of Revenue                                                                                                                               14
                                                                                                                                                               9999
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16          First name                                                  Last name                       Social Security number (SSN)                                   16
17          XXXXXXXXXXXX                                                XXXXXXXXXXXXXXXXXXXX            999-99-9999–                                 –                 17
18          Spouse first name                                           Spouse last name                Spouse SSN                                                     18
19          XXXXXXXXXXXX                                                XXXXXXXXXXXXXXXXXXXX            999-99-9999–                                 –                 19
20          Current mailing address                                                                                                                                    20
21                                                                                                                                                                     21
22          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCity                     State            ZIP code       Phone                                                          22

23                                                                      XX               XXXXX-XXXX     (999)(                                    )  999-9999–         23
24          XXXXXXXXXXXXXXXXXXXXX                                                                                                                                      24
25          Part I—Tax return information                                                                                                                              25
26                                                                                                                                                                     26
27          1. Net refund (Form OR-40, Form OR-40-N, or Form OR-40-P) ........................................................................... 1. 999,999,999.00.00 27
28          2. Amount you owe (Form OR-40, Form OR-40-N, or Form OR-40-P) ................................................................ 2.        999,999,999.00.00 28
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30                                                                                                                                                                     30
31          Part II—Direct deposit of refund or direct debit (see instructions)                                                                                        31
32                                                                                                                                                                     32
33          3.  Routing number    999999999                                              Caution:                                                                      33
34                                                                                       Oregon is unable to change account information. Verify that your              34
35          4.  Account number    XXXXXXXXXXXXXXXXX                                      banking information is correct. Entering incorrect information will           35
36                                                                                       cause a delay in your refund or rejection of your payment.                    36
37          5.  Type of account   X  Checking           or  X Savings                                                                                                  37
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39                                                                                                                                                                     39
40          Part III—Declaration of taxpayer(s)                                                                                                                        40
41                                                                                                                                                                     41
42            6a.  X   I consent that my refund be directly deposited as designated in the electronic portion of my Oregon income tax return                           42
43                     (Form OR-40, Form OR-40-N, or Form OR-40-P). If I have filed a joint return, this is an irrevocable appointment of my                           43
44                     spouse as an agent to receive the refund.                                                                                                       44
45                                                                                                                                                                     45
46            6b.  X   I am receiving a refund but I don’t want to receive it by direct deposit.                                                                       46
47                                                                                                                                                                     47
48            6c.  X   I consent that the return payment is made by direct debit using the account designated above. If I have filed a joint                           48
49                     return, I am authorizing this payment on behalf of my spouse and myself.                                                                        49
50                                                                                                                                                                     50
51            6d.  X   I am not receiving a refund or making an electronic payment.                                                                                    51
52                                                                                                                                                                     52
53          Under penalties for false swearing, I declare that I have compared the information contained on my return with the information I have provided to          53
54          my electronic return originator (ERO) or online service provider (OLSP) and that the amounts described in Part I above agree with the amounts              54
55          shown on the corresponding lines of my Oregon income tax return. To the best of my knowledge and belief, my return is true, correct, and                   55
56          complete. I consent that my return, including this declaration and accompanying schedules and statements, be forwarded upon request to                     56
57          the Oregon Department of Revenue (DOR) by my ERO or OLSP. If the processing of my return, payment, or refund is delayed, I authorize the                   57
58          department to disclose to my preparer the reason(s) for the delay and the date the payment was posted to my account or the refund was sent.                58
59                                                                                                                                                                     59
60          Sign   Your signature                                                        Date                                                                          60
                   X
61          here➤                                                                        99/99/9999/ /                                                                 61
62                 Spouse signature (if filing jointly, both must sign)                  Date                                                                          62
63                 X                                                                     99/99/9999/ /                                                                 63
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71           Form OR-EF                                                                                                                                                    71
72           Page 2 of 2, 150-101-339                   Oregon Department of Revenue   01610001020000                                                                      72
73           (Rev. 08-19-22, ver. 01)                                                                                                                                      73
74                                                                                                                                                                         74
75           Part IV—Declaration of electronic return originator (ERO) or paid preparer                                                                                    75
76           I declare that I have reviewed the above taxpayer’s return and that the entries on this form are complete and correct to the best of my knowledge. If I       76
77           am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects data on the return. The taxpayer will  77
78           have signed this form before I submit the return. I will give the taxpayer a copy of all forms and information to be filed with Oregon, and have followed all 78
79           other requirements described in the Modernized Electronic Filing Handbook for Software Developers and Tax Preparers. If I am also the paid preparer,          79
80           under penalty of perjury I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of             80
81           my knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.                    81
82                                                                                                                                                                         82
83           Electronic return originator’s use only                                                                                                                       83
84           ERO signature                              Date                                    Check if                         Check if                                  84
                                                                                        X                                       X
85           X                                          99/99/9999/                  /          paid preparer                    self-employed                             85
86           Firm name (or your name, if self-employed)                                 Phone                                    ERO license number                        86
87           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                        (999)( ) 999-9999–                      XXXXXXXXXX                                 87
88           ERO address                                City                                             State                   ZIP code                                  88
89                                                                                                                                                                         89
90           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX                                                       XXXXX-XXXX                                 90
91           Under penalty of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best               91
92           of my knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.                 92
93                                                                                                                                                                         93
94           Paid preparer’s use only                                                                                                                                      94
95           Preparer signature                         Date                                    Check if                                                                   95
                                                                                        X
96           X                                          99/99/9999/                  /          self-employed                                                              96
97           Firm name (or yours if self-employed)                                      Phone                                    Certificate/license number                97
98           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                        (999)( ) 999-9999–                      XXXXXXXXXX                                 98
99           Preparer address                           City                                             State                   ZIP code                                  99
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             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX                                                       XXXXX-XXXX
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102                                   Don’t mail this form or your paper return to the Oregon Department of Revenue                                                        102
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