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4                                                                                                                                                                          4
5                                                                                                                       Oregon Department of Revenue                       5
                  2022 Form OR-CAT
6                 Oregon Corporate Activity Tax Return                                                                                                                     6
7                                                                                                                                                                          7
8                 Page 1 of 7        • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.           8
9           Fiscal year beginning (MM/DD/YYYY)            Fiscal year ending (MM/DD/YYYY)                                                                                  9
10                                                                                                                                                                         10
11          99/99/9999/        /                          99/99/9999/       /                                                                                              11
12                                                                                                                                                                         12
13          See instructions for checkboxes.                                                                                                                               13
14                                                                                                                                                                         14
15          X     Extension    X             Amended      X Alternative apportionment request included (see instructions)                                                  15
16                                                                                                                                                                         16
17                                                                                                                                                                         17
18          X     New name     X             New address  X Accounting period change                                                                                       18
19                                                                                                                                                                         19
20                                              Date beginning (MM/DD/YYYY)               Date ending (MM/DD/YYYY)                                                         20
21          X     Short-year returns                                                                                                                                       21
22                                              99/99/9999/ /                             99/99/9999/             /                                                        22
23                                                                                                                                                                         23
24          Legal name of designated Corporate Activity Tax (CAT) entity (sole proprietor—complete the next line)                                                          24
25                                                                                                                                                                         25
26                                                                                                                                                                         26
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
27          First name (if sole proprietorship)             Initial         Last name                                                                                      27
28                                                                                                                                                                         28
29                                                                                                                                                                         29
            XXXXXXXXXXXXXXXX                                X               XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
30          Federal employer identification number (FEIN) Social Security number (SSN)                                                                                     30
31                                                                                                                                                                         31
32          99-9999999                                    999-99-9999                                             X     Deceased                                           32
33          Doing business as (DBA)                                                                                                                                        33
34                                                                                                                                                                         34
35                                                                                                                                                                         35
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
36          Current address                                                                                                                                                36
37                                                                                                                                                                         37
38                                                                                                                                                                         38
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
39          City                                                                                                  State         ZIP code                                   39
40                                                                                                                                                                         40
41          XXXXXXXXXXXXXXXXXXXXXX                                                                                XX            XXXXX-XXXX -                               41
42          Country (if other than the U.S.)                                                                      Contact phone                                            42
43                                                                                                                                                                         43
44                                                                                                                                                                         44
            XXXXXXXXXXXXXXXXXXXXX                                                                                 999-999-9999
45          Contact first name                              Initial         Contact last name                                                                              45
46                                                                                                                                                                         46
47                                                                                                                                                                         47
            XXXXXXXXXXXXXXXX                                X               XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
48          Email                                                                                                                                                          48
49                                                                                                                                                                         49
50                                                                                                                                                                         50
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
51                                                                                                                                                                         51
52                                                                                                                                                                         52
53                                                                                                                                                                         53
54                                                                                                                                                                         54
55                                                                                                                                                                         55
56                                                                                                                                                                         56
57                                                                                                                                                                         57
58                                                                                                                                                                         58
59                                                                                                                                                                         59
60                                                                                                                                                                         60
61                                                                                                                                                                         61
62                                                                                                                                                                         62
                  150-106-003
63                (Rev. 06-10-22, ver. 01)                                                                                      20532201010000                             63
64                                                                                                                                                                         64
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67                                                                                                                                                                                                67
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69                                                                                                                                                                                                69
70                                                                                                                                                                                                70
71                  2022 Form OR-CAT                                                                                            Oregon Department of Revenue                                      71
72                                                                                                                                                                                                72
73                                                                                                                                                                                                73
74                  Page 2 of 7            • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                            74
75           A. Incorporated in (state)      Incorporated on (date) (MM/DD/YYYY)                                                                                                                  75
76                                                                                                                                                                                                76
77           XX                              99/99/9999/        /                                                                                                                                 77
78           B. State of commercial domicile                                                                                                                                                      78
79                                                                                                                                                                                                79
80                                                                                                                                                                                                80
             XX
81           C. Business activity code       D. Tax entity type E. Legal entity type                                                                                                              81
82                                                                                                                                                                                                82
83                                                                                                                                                                                                83
                  999999                     XX                 XX
84                                                                                                                                                                                                84
85                                                                                                                                                                                                85
86           F.   X Consolidated federal return                 X Entities included in consolidated federal return, but not in Oregon return                                                      86
87                                                                                                                                                                                                87
88                X Combined Oregon return                      X Entities included in combined Oregon return, but not in federal return                                                          88
89                                                                                                                                                                                                89
90                X Elect to file as modified unitary group                                                                                                                                       90
91                                                                                                                                                                                                91
92           G. Name of parent corporation, if different than designated CAT entity (if applicable)                                                                                               92
93                                                                                                                                                                                                93
94                                                                                                                                                                                                94
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
95           FEIN of parent corporation, if different than designated CAT entity (if applicable)                                                                                                  95
96                                                                                                                                                                                                96
97                                                                                                                                                                                                97
             99-9999999
98           H. Number of affiliates included in this return (You must include Schedule OR-AF-CAT if this is a combined return)                                                                   98
99                                                                                                                                                                                                99
100                                                                                                                                                                                               100
                  999999
101                                                                                                                                                                                               101
102          I. List the tax years for which federal waivers of the statute of limitations are in effect (YYYY)                                                                                   102
103                                                                                                                                                                                               103
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
104                                                                                                                                                                                               104
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
105          Dates which waivers expire (MM/DD/YYYY)                                                                                                                                              105
106                                                                                                                                                                                               106
107          99/99/9999/ /                           99/99/9999/                 /                              99/99/9999/     /                                                                 107
108                                                                                                                                                                                               108
109          J. List the tax years your federal income attributable to Oregon commercial activity was changed by an IRS audit or by an amended federal return filed during this tax year.  (YYYY) 109
110                                                                                                                                                                                               110
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
111                                                                                                                                                                                               111
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
112                                                                                                                                                                                               112
113          K. If first return, indicate:   X New business     X Successor to previous business                                                                                                  113
114                                                                                                                                                                                               114
115          Previous business name                                                                                                                                                               115
116                                                                                                                                                                                               116
117                                                                                                                                                                                               117
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
118          FEIN                                                                                                                                                                                 118
119                                                                                                                                                                                               119
120                                                                                                                                                                                               120
             99-9999999
121                                                                                                                                                                                               121
122                                                                                                                                                                                               122
123                                                                                                                                                                                               123
124                                                                                                                                                                                               124
125                                                                                                                                                                                               125
126                                                                                                                                                                                               126
127                                                                                                                                                                                               127
128                                                                                                                                                                                               128
                    150-106-003
129                 (Rev. 06-10-22, ver. 01)                                                                                    20532201020000                                                    129
130                                                                                                                                                                                               130
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69                                                                                                                                                                                   69
70                                                                                                                                                                                   70
71                       2022 Form OR-CAT                                                                                                           Oregon Department of Revenue     71
72                                                                                                                                                                                   72
73                                                                                                                                                                                   73
74                       Page 3 of 7       • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.               74
75                                                                                                                                                                                   75
76           L. If final return, indicate:    X       Withdrawn        X      Dissolved                                          X Merged or reorganized                             76
77                                                                                                                                                                                   77
78           Merged or reorganized business name                                                                                                                                     78
79                                                                                                                                                                                   79
80                                                                                                                                                                                   80
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
81           FEIN                                                                                                                                                                    81
82                                                                                                                                                                                   82
83                                                                                                                                                                                   83
             99-9999999
84                                                                                                                                                                                   84
85           M.     X       Financial institution          N.    X   Insurer    O.            X                                  Farming operation                                   85
86                                                                                                                                                                                   86
87                                                                                                                                                                                   87
88                                                                                                                                                                                   88
89             1.  Oregon commercial activity plus exclusions ...........................................1.                        ,                     , 99,999,999,999.00,    0 0 89
90                                                                                                                                                                                   90
91                                                                                                                                                                                   91
92             2.  Total exclusions from commercial activity (attach schedule OR-EXC-CAT) ....2.                                   ,                     , 99,999,999,999.00,    0 0 92
93                                                                                                                                                                                   93
94                                                                                                                                                                                   94
95             3.  Oregon commercial activity, line 1 minus line 2 .......................................3.                       ,                     , 99,999,999,999.00,    0 0 95
96                                                                                                                                                                                   96
97                  X       Substitute method (see instructions).                                                                                                                    97
98                                                                                                                                                                                   98
99             4.  Cost inputs ...............................................................................................4.   ,                     , 99,999,999,999.00,    0 0 99
100                                                                                                                                                                                  100
101                                                                                                                                                                                  101
102            5.  Labor costs (not to exceed $500,000 for any single employee) ..............5.                                   ,                     , 99,999,999,999.00,    0 0 102
103                                                                                                                                                                                  103
104                                                                                                                                                                                  104
105            6.  Multiply either line 4 or line 5, whichever is greater, by 35 percent and                                                                                         105
106                 round the product to the nearest whole dollar ............................................6.                   ,                     , 99,999,999,999.00,    0 0 106
107                                                                                                                                                                                  107
108            7.  Apportionment percentage of subtraction (see instructions). Include                                                                                               108
109                 an attachment showing calculations. ......................................................7.                     999.9999 %                                      109
110                                                                                                                                                                                  110
111                                                                                                                                                                                  111
112            8.  Multiply line 6 by line 7. This is your CAT subtraction .............................8.                         ,                     , 99,999,999,999.00,    0 0 112
113                                                                                                                                                                                  113
114                                                                                                                                                                                  114
115            9.  Commercial activity after subtraction, line 3 minus line 8 .......................9.                            ,                     , 99,999,999,999.00,    0 0 115
116                                                                                                                                                                                  116
117                                                                                                                                                                                  117
118            10.  Subcontractor exclusion (see instructions) ............................................10.                     ,                     , 99,999,999,999.00,    0 0 118
119                                                                                                                                                                                  119
120                                                                                                                                                                                  120
121            11.  Taxable Oregon commercial activity, line 9 minus line 10 .....................11.                              ,                     , 99,999,999,999.00,    0 0 121
122                                                                                                                                                                                  122
123                                                                                                                                                                                  123
124            12.  $1 million threshold ................................................................................12.                               1,000,000.00              124
125                                                                                                                                                                                  125
126                                                                                                                                                                                  126
127                                                                                                                                                                                  127
128                                                                                                                                                                                  128
                         150-106-003
129                      (Rev. 06-10-22, ver. 01)                                                                                                        20532201030000              129
130                                                                                                                                                                                  130
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67                                                                                                                                                                         67
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69                                                                                                                                                                         69
70                                                                                                                                                                         70
71                        2022 Form OR-CAT                                                                                          Oregon Department of Revenue           71
72                                                                                                                                                                         72
73                                                                                                                                                                         73
74                        Page 4 of 7   • 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             13.  Taxable Oregon commercial activity in excess of $1 million threshold ....13.                                  , , 99,999,999,999.00,            0 0    77
78                                                                                                                                                                         78
79                                                                                                                                                                         79
80             14.  Multiply line 13 by 0.57 percent. Round to the nearest whole dollar .....14.                                  , , 99,999,999,999.00,            0 0    80
81                                                                                                                                                                         81
82                                                                                                                                                                         82
83             15.  Base tax .................................................................................................15.                                   250.00 83
84                                                                                                                                                                         84
85                                                                                                                                                                         85
86             16.  Total CAT (line 14 plus line 15). If the amount on line 11 is less than                                                                                86
87                  line 12 enter 0 ..........................................................................................16. , , 99,999,999,999.00,            0 0    87
88                                                                                                                                                                         88
89                                                                                                                                                                         89
90             17.  2022 Estimated CAT payments and other prepayments from                                                                                                 90
91                  Schedule OR-ES-CAT line 7. Include payments made with extension ...... 17.                                    , , 99,999,999,999.00,            0 0    91
92                                                                                                                                                                         92
93                                                                                                                                                                         93
94             18.  Tax due. Is line 16 more than line 17? If so, line 16 minus line 17 ........18.                               , , 99,999,999,999.00,            0 0    94
95                                                                                                                                                                         95
96                                                                                                                                                                         96
97             19.  Overpayment. Is line 16 less than line 17? If so, line 17 minus line 16 ....                  19.             , , 99,999,999,999.00,            0 0    97
98                                                                                                                                                                         98
99                                                                                                                                                                         99
100            20.  Penalty due with this return (see instructions) ...................................... 20.                    , , 99,999,999,999.00,            0 0    100
101                                                                                                                                                                        101
102                                                                                                                                                                        102
103            21.  Total due. Line 18 plus line 20 ............................................................. 21.             , , 99,999,999,999.00,            0 0    103
104                                                                                                                                                                        104
105                                                                                                                                                                        105
106            22.  Refund available. Line 19 minus line 20 ..............................................        22.             , , 99,999,999,999.00,            0 0    106
107                                                                                                                                                                        107
108                                                                                                                                                                        108
109            23.  Amount of refund you want applied to your estimated tax account .....                         23.             , , 99,999,999,999.00,            0 0    109
110                                                                                                                                                                        110
111                                                                                                                                                                        111
112            24.  Net refund. Line 22 minus line 23 ........................................................    24.             , , 99,999,999,999.00,            0 0    112
113                                                                                                                                                                        113
114                                                                                                                                                                        114
115                                                                                                                                                                        115
116                                                                                                                                                                        116
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118                                                                                                                                                                        118
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                          150-106-003
129                       (Rev. 06-10-22, ver. 01)                                                                                  20532201040000                         129
130                                                                                                                                                                        130
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69                                                                                                                                                                        69
70                                                                                                                                                                        70
71                    2022 Form OR-CAT                                                                                           Oregon Department of Revenue             71
72                                                                                                                                                                        72
73                                                                                                                                                                        73
74                    Page 5 of 7         • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.     74
75                                                                                                                                                                        75
76           Schedule OR-ES-CAT – Estimated Tax Payments and Other Prepayments                                                                                            76
77                                                                                                                                                                        77
78           Quarter 1                                                                                                                                                    78
79           Legal name of payer, if an entity                                                                                                                            79
80                                                                                                                                                                        80
81                                                                                                                                                                        81
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
82           If individual, name of payer      Initial     Last name                                                                                                      82
83                                                                                                                                                                        83
84                                                                                                                                                                        84
             XXXXXXXXXXXXXXXX                  X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
85           Payer’s FEIN                      Payer’s SSN                                                                       Date paid (MM/DD/YYYY)                   85
86                                                                                                                                                                        86
87           99-9999999                        999-99-9999                                                                       99/99/9999/ /                            87
88                                                                                                                                                                        88
89                                                                                                                                                                        89
90             1.  Amount paid ........................................................................................... 1.  , , 99,999,999,999.00,                 0 0 90
91                                                                                                                                                                        91
92           Quarter 2                                                                                                                                                    92
93           Legal name of payer, if an entity                                                                                                                            93
94                                                                                                                                                                        94
95                                                                                                                                                                        95
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
96           If individual, name of payer      Initial     Last name                                                                                                      96
97                                                                                                                                                                        97
98                                                                                                                                                                        98
             XXXXXXXXXXXXXXXX                  X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
99           Payer’s FEIN                      Payer’s SSN                                                                       Date paid (MM/DD/YYYY)                   99
100                                                                                                                                                                       100
101          99-9999999                        999-99-9999                                                                       99/99/9999/ /                            101
102                                                                                                                                                                       102
103                                                                                                                                                                       103
104            2.  Amount paid ........................................................................................... 2.  , , 99,999,999,999.00,                 0 0 104
105                                                                                                                                                                       105
106                                                                                                                                                                       106
             Quarter 3
107          Legal name of payer, if an entity                                                                                                                            107
108                                                                                                                                                                       108
109                                                                                                                                                                       109
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
110          If individual, name of payer      Initial     Last name                                                                                                      110
111                                                                                                                                                                       111
112                                                                                                                                                                       112
             XXXXXXXXXXXXXXXX                  X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
113          Payer’s FEIN                      Payer’s SSN                                                                       Date paid (MM/DD/YYYY)                   113
114                                                                                                                                                                       114
115          99-9999999                        999-99-9999                                                                       99/99/9999/ /                            115
116                                                                                                                                                                       116
117                                                                                                                                                                       117
118            3.  Amount paid ........................................................................................... 3.  , , 99,999,999,999.00,                 0 0 118
119                                                                                                                                                                       119
120                                                                                                                                                                       120
121                                                                                                                                                                       121
122                                                                                                                                                                       122
123                                                                                                                                                                       123
124                                                                                                                                                                       124
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128                                                                                                                                                                       128
                      150-106-003
129                   (Rev. 06-10-22, ver. 01)                                                                                   20532201050000                           129
130                                                                                                                                                                       130
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70                                                                                                                                                                        70
71                        2022 Form OR-CAT                                                                                         Oregon Department of Revenue           71
72                                                                                                                                                                        72
73                                                                                                                                                                        73
74                        Page 6 of 7     • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.     74
75           Quarter 4                                                                                                                                                    75
76           Legal name of payer, if an entity                                                                                                                            76
77                                                                                                                                                                        77
78                                                                                                                                                                        78
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
79           If individual, name of payer                         Initial Last name                                                                                       79
80                                                                                                                                                                        80
81                                                                                                                                                                        81
             XXXXXXXXXXXXXXXX                                     X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
82           Payer’s FEIN                                 Payer’s SSN                                                              Date paid (MM/DD/YYYY)                 82
83                                                                                                                                                                        83
84           99-9999999                                   999-99-9999                                                              99/99/9999/ /                          84
85                                                                                                                                                                        85
86                                                                                                                                                                        86
87             4.  Amount paid ........................................................................................... 4.    , , 99,999,999,999.00,               0 0 87
88                                                                                                                                                                        88
89                                                                                                                                                                        89
90             5.  Overpayment of another year’s tax applied as a credit against this                                                                                     90
91               year’s tax ................................................................................................. 5. , , 99,999,999,999.00,               0 0 91
92           Payer’s FEIN                                 Payer’s SSN                                                                                                     92
93                                                                                                                                                                        93
94                                                                                                                                                                        94
95           99-9999999                                   999-99-9999                                                                                                     95
96                                                                                                                                                                        96
97             6.  Payments made with extension or other prepayments for this tax year ...                                    6. , , 99,999,999,999.00,               0 0 97
98           Legal name of payer, if an entity                                                                                                                            98
99                                                                                                                                                                        99
100                                                                                                                                                                       100
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
101          If individual, name of payer                         Initial Last name                                                                                       101
102                                                                                                                                                                       102
103                                                                                                                                                                       103
             XXXXXXXXXXXXXXXX                                     X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
104          Payer’s FEIN                                 Payer’s SSN                                                              Date paid (MM/DD/YYYY)                 104
105                                                                                                                                                                       105
106          99-9999999                                   999-99-9999                                                              99/99/9999/ /                          106
107                                                                                                                                                                       107
108                                                                                                                                                                       108
109            7.  Total prepayments (carry to line 17 on page 4) ....................................... 7.                     , , 99,999,999,999.00,               0 0 109
110                                                                                                                                                                       110
111                                                                                                                                                                       111
112                                                                                                                                                                       112
113                                                                                                                                                                       113
114                                                                                                                                                                       114
115                                                                                                                                                                       115
116                                                                                                                                                                       116
117                                                                                                                                                                       117
118                                                                                                                                                                       118
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                          150-106-003
129                       (Rev. 06-10-22, ver. 01)                                                                                 20532201060000                         129
130                                                                                                                                                                       130
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69                                                                                                                                                                69
70                                                                                                                                                                70
71                2022 Form OR-CAT                                                               Oregon Department of Revenue                                     71
72                                                                                                                                                                72
73                                                                                                                                                                73
74                Page 7 of 7         • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples. 74
75                                                                                                                                                                75
76           Under penalty of false swearing, I declare that the information in this return and any enclosures is true, correct, and complete.                    76
77                                                                                                                                                                77
78           Signature of taxpayer or officer                                                                                                                     78
79                                                                                                                                                                79
80           X                                                                                                                                                    80
81           Date (MM/DD/YYYY)                                                                                                                                    81
82                                                                                                                                                                82
83           99/99/9999/            /                                                                                                                             83
84           First name of officer                           Initial Last name of officer                                                                         84
85                                                                                                                                                                85
86                                                                                                                                                                86
             XXXXXXXXXXXXXXXX                                X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
87           Title of officer                                                                                                                                     87
88                                                                                                                                                                88
89                                                                                                                                                                89
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
90                                                                                                                                                                90
91           Signature of preparer other than taxpayer                                                                                                            91
92                                                                                                                                                                92
93           X                                                                                                                                                    93
94           Date (MM/DD/YYYY)                         Phone                                     License number of preparer                                       94
95                                                                                                                                                                95
96           99/99/9999/            /                  999-999-9999                              XXXXXXXXXX                                                       96
97           First name of preparer                          Initial Last name of preparer                                                                        97
98                                                                                                                                                                98
99                                                                                                                                                                99
             XXXXXXXXXXXXXXXX                                X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
100          Address of preparer                                                                                                                                  100
101                                                                                                                                                               101
102                                                                                                                                                               102
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
103          City                                                                          State ZIP code                                                         103
104                                                                                                                                                               104
105          XXXXXXXXXXXXXXXXXXXXXX                                                        XX    XXXXX-XXXX -                                                     105
106                                                                                                                                                               106
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                  150-106-003
129               (Rev. 06-10-22, ver. 01)                                                       20532201070000                                                   129
130                                                                                                                                                               130
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