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2022 Form OR-STI
6 Page 1 of 1, 150-101-071 Oregon Department of Revenue 19342201010000 6
7 (Rev. 08-05-22, ver. 01) 7
8 Oregon Statewide Transit Individual Tax Return 8
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11 Submit original form—do not submit photocopy. 11
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13 X Amended return X Extension filed 13
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15 First name Initial Last name Social Security number (SSN) 15
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17 XXXXXXXXXXXXCurrent mailing address X XXXXXXXXXXXXXXXXXXXX 999-99-9999Date of-birth- 17
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19 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCity State ZIP code Country 99/99/9999Phone/ / 19
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XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX XXXXXXXXXXXXXXXXXXXXX ((999)) 999-9999-
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22 Caution: This form applies to a limited number of employees. See the instructions before filing this form. 22
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24 1. Taxable wages (see instructions) ..........................................................................................................1. 99,999,999,999.00.00 24
25 2. Tax. Line 1 multiplied by 0.001. Round to the nearest dollar ...............................................................2. 99,999,999,999.00.00 25
26 3. Tax withheld from Form(s) W-2 box 14 (see instructions). Include a copy of your Form(s) W-2. .........3. 99,999,999,999.00.00 26
27 4. Enter payments you made prior to the filing of this return (see instructions) .......................................4. 99,999,999,999.0099,999,999,999.00.00.00 27
28 5. Total payments and tax withheld. Add lines 3 and 4 ........................................................................5. 99,999,999,999.0099,999,999,999.00.00.00 28
29 6. Penalty and interest for filing or paying late (see instructions) .............................................................6. 99,999,999,999.00.00 29
30 7. Tax plus penalty and interest. Add lines 2 and 6 ..................................................................................7. 99,999,999,999.00.00 30
31 8. Tax to pay. If line 5 is less than line 7, you have tax to pay. Line 7 minus line 5 .................................8. 99,999,999,999.00.00 31
32 9. Refund. If line 5 is more than line 7, you overpaid. Line 5 minus line 7 ..............................................9. 99,999,999,999.00.00 32
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35 Direct deposit 35
36 10. For direct deposit of your refund, see instructions. Check the box if this refund will go to an account outside the United States: 36
X
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38 Type of account: Checking or Savings 38
X X
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40 Routing number: 40
999999999
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42 Account number: 42
XXXXXXXXXXXXXXXXX
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46 Sign here. Under penalty of false swearing, I declare the information in this return and any attachments is true, correct, and complete. 46
47 Your signature Date 47
48 X 99/99/9999/ / 48
49 Signature of preparer other than taxpayer Preparer phone Preparer license number, if professionally prepared 49
50 X ((999))999-9999– XXXXXXXXXX 50
51 Preparer mailing address City State ZIP code 51
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
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Important: Include a copy of your Form(s) W-2. We may adjust your return without it.
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55 File and pay online: 55
56 You may file and pay electronically at www.oregon.gov/dor by using Revenue Online. 56
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Mail your return and payment:
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For payments make your check or money order payable to “Oregon Department of Revenue.”
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Write “2022 Oregon Form OR-STI” and the last four digits of your social security number on the memo line. Don’t mail cash.
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61 Mail to: Oregon Department of Revenue, PO Box 14555, Salem OR 97309-0940. 61
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