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5                                                                                                                                    Oregon Department of Revenue             5
                        2022 Form OR-LTD
6                       Lane County Mass Transit District  Self-employment Tax                                                                                                6
7                                                                                                                                                                             7
8                       Page 1 of 2     • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.           8
9                                You may file this return directly with us through Revenue Online, at  www.oregon.gov/dor.                                                    9
10          Fiscal year beginning (MM/DD/YYYY)               Fiscal year ending (MM/DD/YYYY)                                                                                  10
11                                                                                                                                                                            11
12          99/99/9999/            /                         99/99/9999/                               /                                                                      12
13                                                                                                                                                                            13
14          See instructions for checkboxes (check all that apply)                                                                                                            14
15                                                                                                                                                                            15
16          X     Amended return           X      Name change          X       Address change                                X An extension has been filed                    16
17                                                                                                                                                                            17
18          X     Utility or telecommunications                                                                                                                               18
19                                                                                                                                                                            19
20          Did you file Form OR-LTD for 2021?           X Yes         X       No (if no, give reason.)                      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                20
21                                                                                                                                                                            21
                                                                                                                             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22                                                                                                                                                                            22
23          First name                                                 Initial    Last name                                                                                   23
24                                                                                                                                                                            24
25                                                                                                                                                                            25
            XXXXXXXXXXXXXXXX                                           X          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
26          Partnership name (if filer is a partnership)                                                                                                                      26
27                                                                                                                                                                            27
28                                                                                                                                                                            28
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
29          Social Security number (SSN)                         Federal employer identification number (FEIN)                       Phone                                    29
30                                                                                                                                                                            30
31                                                                                                                                                                            31
            999-99-9999                                          99-9999999                                                          999-999-9999
32          Business address                                                                                                                                                  32
33                                                                                                                                                                            33
34                                                                                                                                                                            34
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
35          County                                                                                                                                                            35
36                                                                                                                                                                            36
37                                                                                                                                                                            37
            XXXXXXXXXXXXXXXXXXXXXXXXX
38          City                                                                                                               State ZIP code                                 38
39                                                                                                                                                                            39
40          XXXXXXXXXXXXXXXXXXXXXX                                                                                             XX    XXXXX-XXXX -                             40
41                                                                                                                                                                            41
42                                                                                                                                                                            42
43            1.  Self-employment earnings from federal Schedule SE or                                                                                                        43
44                Partnership Form 1065 ............................................................................1.         ,     ,     99,999,999,999.00,       0 0       44
45                                                                                                                                                                            45
46            2.  Apportionment percentage from Schedule OR-TSE-AP .........................2.                                   999.9999 %                                   46
47                                                                                                                                                                            47
48            3.  Net self-employment earnings. Multiply line 1 by line 2 ..........................3.                         ,     ,     99,999,999,999.00,       0 0       48
49                                                                                                                                                                            49
50            4.  Less: Exclusion. Not more than $400 per taxpayer .................................4.                         ,     ,     99,999,999,999.00,       0 0       50
51                                                                                                                                                                            51
52            5.  Net earnings subject to transit district tax. Line 3 minus line 4 ...............5.                          ,     ,     99,999,999,999.00,       0 0       52
53                                                                                                                                                                            53
54            6.  Net tax. Multiply the amount on line 5 by 0.0077 ....................................6.                      ,     ,     99,999,999,999.00,       0 0       54
55                                                                                                                                                                            55
56            7.  Prepayments ............................................................................................7.   ,     ,     99,999,999,999.00,       0 0       56
57            8. Tax to pay.  If line 6 is more than line 7, you have tax to pay.                                                                                             57
58                Line 6 minus line 7 .................................................................Tax to pay 8.           ,     ,     99,999,999,999.00,       0 0       58
59                                                                                                                                                                            59
60                                                                                                                                                                            60
61                                                                                                                                                                            61
62                                                                                                                                                                            62
                        150-560-001
63                      (Rev. 08-08-22, ver. 01)                                                                                           08562201010000                     63
64                                                                                                                                                                            64
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69                                                                                                                                                                       69
70                                                                                                                                                                       70
                                                                                                                             Oregon Department of Revenue
71                        2022 Form OR-LTD                                                                                                                               71
72                                                                                                                                                                       72
73                                                                                                                                                                       73
74                        Page 2 of 2    • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.     74
75                                                                                                                                                                       75
76                                                                                                                                                                       76
77             9.  Penalty and interest for filing or paying late .............................................9.      ,     , 99,999,999,999.00,                    0 0 77
78                                                                                                                                                                       78
79             10.  Total amount due. Line 8 plus line 9 ....................................Total due 10.             ,     , 99,999,999,999.00,                    0 0 79
80             11. Refund.  If line 7 is more than line 6, you overpaid.                                                                                                 80
81                  Line 7 minus line 6 ....................................................................Refund 11. ,     , 99,999,999,999.00,                    0 0 81
82                                                                                                                                                                       82
83           Business activity:     X       Sales       X    Services                                                                                                    83
84                                                                                                                                                                       84
85                                  X       Other (explain)  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                       85
86                                                                                                                                                                       86
87           Individuals:        You must include a copy of your federal Schedule SE.                                                                                    87
88                                                                                                                                                                       88
89           Partnerships:       You must include a schedule listing each partner’s name, Social Security number, partnership earnings, and exclusion.                   89
90                                                                                                                                                                       90
91           Apportioning:       You must include your completed Schedule OR-TSE-AP. If you don't provide your schedule as required, an unnecessary                      91
92                               billing for tax may occur.                                                                                                              92
93                                                                                                                                                                       93
94           Under penalty of false swearing, I declare that the information in this return and any enclosures are true, correct, and complete.                          94
95             Your signature                                                                                                                                            95
96                                                                                                                                                                       96
97           X                                                                                                                                                           97
98           Date (MM/DD/YYYY)                                                                                                                                           98
99                                                                                                                                                                       99
100          99/99/9999/            /                                                                                                                                    100
101                                                                                                                                                                      101
102            Preparer signature other than taxpayer                                                                                                                    102
103                                                                                                                                                                      103
104          X                                                                                                                                                           104
105          Date (MM/DD/YYYY)                               Phone                                                           Preparer license number                     105
106                                                                                                                                                                      106
107          99/99/9999/            /                        999-999-9999                                                    XXXXXXXXXX                                  107
108          Preparer first name                                   Initial Preparer last name                                                                            108
109                                                                                                                                                                      109
110                                                                                                                                                                      110
             XXXXXXXXXXXXXXXX                                      X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
111          Preparer address                                                                                                                                            111
112                                                                                                                                                                      112
113                                                                                                                                                                      113
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
114          City                                                                                                      State ZIP code                                    114
115                                                                                                                                                                      115
116          XXXXXXXXXXXXXXXXXXXXXX                                                                                    XX    XXXXX-XXXX -                                116
117                                                                                                                                                                      117
118                                                                                                                                                                      118
119          Pay online or make check or money order payable to: Oregon Department of Revenue                                                                            119
120                                                                                                                                                                      120
121          Mail your return to: LTDSE, Oregon Department of Revenue, PO Box 14555, Salem OR 97309-0940                                                                 121
122                                                                                                                                                                      122
123          Don’t attach your Form OR-LTD self-employment tax return to your Oregon income tax return, or any other form.                                               123
124          Don’t include a payment voucher with this return. Payments included when filing a transit return don’t require a voucher.                                   124
125                                                                                                                                                                      125
126                                                                                                                                                                      126
127                                                                                                                                                                      127
128                                                                                                                                                                      128
                          150-560-001
129                       (Rev. 08-08-22, ver. 01)                                                                           08562201020000                              129
130                                                                                                                                                                      130
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