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5 Form OR-19-AF Office use only 5
6 Page 1 of 1, 150-101-175 Oregon Department of Revenue 15232301010000 6
7 (Rev. 08-25-22, ver. 01) 7
8 Oregon Affidavit 8
9 9
For a nonresident owner of a pass-through entity
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11 Submit original form—do not submit photocopy 11
12 Beginning with tax year: 2023 12
13 Nonresident owner information 13
14 Nonresident owner first name Initial Last name Social Security number (SSN) 14
15 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 15
16 Entity name Federal employer identification number (FEIN) 16
17 99-9999999– 17
18 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet or mailing address 18
19 19
20 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCity State ZIP code Phone 20
21 XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 999-999-9999– – 21
22 Ownership percentage Estimated Oregon-source distributive income each year 22
23 999.9999. % $ 99,999,999,999.00.00 23
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26 Pass-through entity information 26
27 Pass-through entity (PTE) name FEIN 27
28 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999– 28
29 PTE address 29
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31 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCity State ZIP code Phone 31
32 XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 999-999-9999- – - – 32
33 This form must be resubmitted if the PTE information entered above changes or if the ownership percentage of an owner that has filed an 33
34 affidavit changes by 10 percent or more. See Form OR‑19‑AF Instructions. 34
35 Agreement to file 35
36 I agree to timely file all required Oregon income or excise tax return(s) and to make timely payments of all taxes imposed by 36
37 the state of Oregon with respect to my share of the Oregon distributive income from the pass-through entity named above. I 37
38 understand that I am subject to the jurisdiction of the state of Oregon for purposes of the collection of unpaid income 38
39 tax, together with related penalties and interest. 39
40 40
41 Signature 41
42 Taxpayer or authorized agent signature Date 42
43 X 99/99/9999/ / 43
44 Revocation of this affidavit 44
45 By signing below, I declare that: 45
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47 X I am an Oregon resident; 47
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49 X I am subject to tax on the income from the above-listed PTE; 49
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51 X I am no longer an owner in the above-listed PTE; or 51
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53 X I am joining in the filing of an Oregon composite return. 53
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55 Signature 55
56 Taxpayer or authorized agent signature Date 56
57 X 99/99/9999/ / 57
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59 Submit this form at www.oregon.gov/dor using Revenue Online or mail to: 59
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61 Oregon Department of Revenue 61
62 Attn: Processing Center 62
63 955 Center St NE 63
64 Salem OR 97301-2555 64
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