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5 2022 Schedule OR‑OC‑3 Office use only 5
6 Page 1 of 1, 150-101-148 Oregon Department of Revenue 20712201010000 6
7 (Rev. 09-08-22 ver. 01) 7
8 CPAR Adjustments Report for Individuals, Fiduciaries, and Tiered Partners 8
9 9
10 10
11 Submit original form—do not submit photocopy. 11
12 Pass-through entity name Federal employer identification number (FEIN) 12
13 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 13
14 Owner information (see instructions) 14
15 1. Owner type First name Initial Last name Social Security number (SSN) 15
16 XXXXXXXXXXXXXXX XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 16
17 Fiduciary name FEIN 17
18 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 18
19 Ownership percentage Share of federal CPAR adjustments Share of Oregon-source CPAR adjustments 19
20 999.9999. % 99,999,999,999.00.00 99,999,999,999.00.00 20
21 21
22 (a) CPAR tax 22
23 23
99,999,999,999.00.00
24 24
25 2. Owner type First name Initial Last name SSN 25
26 XXXXXXXXXXXXXXX XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 26
27 Fiduciary name FEIN 27
28 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 28
29 Ownership percentage Share of federal CPAR adjustments Share of Oregon-source CPAR adjustments 29
30 999.9999. % 99,999,999,999.00.00 99,999,999,999.00.00 30
31 31
32 (a) CPAR tax 32
33 33
99,999,999,999.00.00
34 34
35 3. Owner type First name Initial Last name SSN 35
36 XXXXXXXXXXXXXXX XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 36
37 Fiduciary name FEIN 37
38 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 38
39 Ownership percentage Share of federal CPAR adjustments Share of Oregon-source CPAR adjustments 39
40 999.9999. % 99,999,999,999.00.00 99,999,999,999.00.00 40
41 41
42 (a) CPAR tax 42
43 43
99,999,999,999.00.00
44 44
45 4. Owner type First name Initial Last name SSN 45
46 XXXXXXXXXXXXXXX XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 46
47 Fiduciary name FEIN 47
48 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 48
49 Ownership percentage Share of federal CPAR adjustments Share of Oregon-source CPAR adjustments 49
50 999.9999. % 99,999,999,999.00.00 99,999,999,999.00.00 50
51 51
52 (a) CPAR tax 52
53 53
99,999,999,999.00.00
54 54
55 5. Total CPAR tax 55
56 Total column (a) 56
57 57
99,999,999,999.00.00
58 58
59 Include this schedule with your Form OR‑OC. 59
60 Use additional copies of this page for additional individuals, fiduciaries, and tiered partners. 60
61 If using more than one page, total all pages on line 5 of the first page. 61
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63 Page _______ 999 of _______999 63
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