1                                                                                                                                                                         1
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3                                                                                                                                                                         3
4                                                                                                                                                                         4
                                                                                                            Oregon Department of Revenue
5                      2022 Form OR-40-P                                                                                                                                  5
6                      Oregon Individual Income Tax Return for Part-year Residents                                                                                        6
7                                                                                                                                                                         7
8                      Page 1 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.           8
9           Fiscal year ending date (MM/DD/YYYY)                                       Space for 2-D barcode—do not write in box below                                    9
10                                                           X Extension filed                                                                                            10
11          99/99/9999/       /                                                                                                                                           11
12                                                           X Form OR-24                                                                                                 12
13          X      Amended return.                                                                                                                                        13
14               If amending for an      NOL tax year (YYYY) X Form OR-243                                                                                                14
15               NOL, tax year the                                                                                                                                        15
16               NOL was generated:             9999         X Federal Form 8379                                                                                          16
17                                                                                                                                                                        17
18          X    Calculated with “as if” federal return      X Federal Form 8886                                                                                          18
19                                                                                                                                                                        19
20          X    Short-year tax election                     X Disaster relief                                                                                            20
21                                                                                                                                                                        21
22          X    Employment exception                        X Military                                                                                                   22
23                                                                                                                                                                        23
24                                       From (MM/DD/YYYY)                       To (MM/DD/YYYY)                                                                          24
25                                                                                                                                                                        25
26          Oregon resident dates:       99/99/9999/         /                   99/99/9999/     /                                                                        26
27                                                                                                                                                                        27
28          First name                                                         Initial Date of birth (MM/DD/YYYY)                                                         28
29                                                                                                                                                                        29
30          XXXXXXXXXXXXXXXX                                                   X       99/99/9999/          /                                                             30
31          Last name                                                                                                                                                     31
32                                                                                                                                                                        32
33                                                                                                                                                                        33
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
34          Social Security number (SSN)                                                                                                                                  34
35                                                                                                                                                                        35
36          999-99-9999                                      X First time using this SSN (see instructions) X     Applied for ITIN  X                           Deceased  36
37                                                                                                                                                                        37
38          Spouse first name                                                  Initial Spouse date of birth (MM/DD/YYYY)                                                  38
39                                                                                                                                                                        39
40          XXXXXXXXXXXXXXXX                                                   X       99/99/9999/          /                                                             40
41          Spouse last name                                                                                                                                              41
42                                                                                                                                                                        42
43                                                                                                                                                                        43
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
44          Spouse SSN                                                                                                                                                    44
45                                                                                                                                                                        45
46          999-99-9999                                      X First time using this SSN (see instructions) X     Applied for ITIN  X                           Deceased  46
47                                                                                                                                                                        47
48          Current address                                                                                                                                               48
49                                                                                                                                                                        49
50                                                                                                                                                                        50
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
51          City                                                                                 State            ZIP code                                                51
52                                                                                                                                                                        52
53                                                                                                                                                                        53
            XXXXXXXXXXXXXXXXXXXXXX                                                               XX               XXXXX-XXXX
54          Country                                                                              Phone                                                                    54
55                                                                                                                                                                        55
56                                                                                                                                                                        56
            XXXXXXXXXXXXXXXXXXXXX                                                                999-999-9999
57                                                                                                                                                                        57
58                                                                                                                                                                        58
59                                                                                                                                                                        59
60                                                                                                                                                                        60
61                                                                                                                                                                        61
62                                                                                                                                                                        62
                       150-101-055
63                     (Rev. 09-12-22, ver. 01)                                                                   00612201010000                                          63
64                                                                                                                                                                        64
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66                                                                                                                                                                        66

67                                                                                                                                                                                                                                       67
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69                                                                                                                                                                                                                                       69
70                                                                                                                                                                                                                                       70
                                                                                                            Oregon Department of Revenue
71                     2022 Form OR-40-P                                                                                                                                                                                                 71
72                                                                                                                                                                                                                                       72
73                                                                                                                                                                                                                                       73
74                     Page 2 of 11  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                                                                         74
75           Last name                                                                        SSN                                                                                                                                        75
76                                                                                                                                                                                                                                       76
77                                                                                                                                                                                                                                       77
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                 999-99-9999
78                                                                                                                                                                                                                                       78
79           Note: Reprint page 1 if you make changes to this page.                                                                                                                                                                      79
80           Filing Status (check only one box)                                                                                                                                                                                          80
81                                                                                                                                                                                                                                       81
82           1. X      Single        2.   X     Married filing jointly 3. X     Married filing separately (enter spouse’s information on page 1)                                                                                         82
83                                                                                                                                                                                                                                       83
84           4. X      Head of household (with qualifying dependent)   5. X     Qualifying surviving spouse                                                                                                                              84
85                                                                                                                                                                                                                                       85
86                                                                                                                                                                                                                                       86
87           Exemptions                                                                                                                                                                                                                  87
88             6a.  Credits for yourself .........................................................................................................................................................................................6a. 9  88
89                                                                                                                                                                                                                                       89
90                Check boxes that apply:       X    Regular  X        Severely disabled X    Someone else can claim you as a dependent                                                                                                  90
91                                                                                                                                                                                                                                       91
92             6b.  Credits for your spouse .................................................................................................................................................................................6b.      9  92
93                                                                                                                                                                                                                                       93
94                Check boxes that apply:       X    Regular  X        Severely disabled X    Someone else can claim you as a dependent                                                                                                  94
95                                                                                                                                                                                                                                       95
96                                                                                                                                                                                                                                       96
97           Dependents. List your dependents in order from youngest to oldest.                                                                                                                                                          97
98           Dependent 1: First name                          Initial  Dependent 1: Last name                                                                                                                                            98
99                                                                                                                                                                                                                                       99
100                                                                                                                                                                                                                                      100
             XXXXXXXXXXXXXXXX                                 X        XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
101          Dependent 1: Date of birth (MM/DD/YYYY) Dependent 1: SSN                         Code *                                                                                                                                     101
102                                                                                                           Dependent 1: Check if child                                                                                                102
103          99/99/9999/      /                      999-99-9999                              XX            X has a qualifying disability                                                                                                103
104                                                                                                                                                                                                                                      104
105          Dependent 2: First name                          Initial  Dependent 2: Last name                                                                                                                                            105
106                                                                                                                                                                                                                                      106
107                                                                                                                                                                                                                                      107
             XXXXXXXXXXXXXXXX                                 X        XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
108          Dependent 2: Date of birth (MM/DD/YYYY) Dependent 2: SSN                         Code *                                                                                                                                     108
109                                                                                                           Dependent 2: Check if child                                                                                                109
110          99/99/9999/      /                      999-99-9999                              XX            X has a qualifying disability                                                                                                110
111                                                                                                                                                                                                                                      111
112          Dependent 3: First name                          Initial  Dependent 3: Last name                                                                                                                                            112
113                                                                                                                                                                                                                                      113
114                                                                                                                                                                                                                                      114
             XXXXXXXXXXXXXXXX                                 X        XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
115          Dependent 3: Date of birth (MM/DD/YYYY) Dependent 3: SSN                         Code *                                                                                                                                     115
116                                                                                                           Dependent 3: Check if child                                                                                                116
117          99/99/9999/      /                      999-99-9999                              XX            X has a qualifying disability                                                                                                117
118                                                                                                                                                                                                                                      118
119          *Dependent relationship code (see instructions).                                                                                                                                                                            119
120                                                                                                                                                                                                                                      120
121            6c.  Total number of dependents ..................................................................................................................................................................6c.                  99 121
122                                                                                                                                                                                                                                      122
123                                                                                                                                                                                                                                      123
124            6d.  Total number of dependent children with a qualifying disability (see instructions) ................................................................................6d.                                            99 124
125                                                                                                                                                                                                                                      125
126                                                                                                                                                                                                                                      126
127                                                                                                                                                                                                                                      127
128                                                                                                                                                                                                                                      128
                       150-101-055
129                    (Rev. 09-12-22, ver. 01)                                                             00612201020000                                                                                                               129
130                                                                                                                                                                                                                                      130
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132                                                                                                                                                                                                                                      132

133                                                                                                                                                                                                           133
  1  2   134   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   134   84 85
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135                                                                                                                                                                                                           135
136                                                                                                                                                                                                           136
                                                                                                            Oregon Department of Revenue
137                    2022 Form OR-40-P                                                                                                                                                                      137
138                                                                                                                                                                                                           138
139                                                                                                                                                                                                           139
140                    Page 3 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                                               140
141          Last name                                                                                 SSN                                                                                                    141
142                                                                                                                                                                                                           142
143                                                                                                                                                                                                           143
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                          999-99-9999
144                                                                                                                                                                                                           144
145          Note: Reprint page 1 if you make changes to this page.                                                                                                                                           145
146                                                                                                                                                                                                           146
147                                                                                                                                                                                                           147
148            6e.  Total exemptions. Add lines 6a through 6d.................................................................................................................................. Total 6e. 99  148
149                                                                                                                                                                                                           149
150          Income                               Federal column (F)                                          Oregon column (S)                                                                               150
151            7.  Wages, salaries, and other pay for work from federal Form 1040 or 1040-SR, line 1z. Include all Forms W-2.                                                                                 151
152                                                                                                                                                                                                           152
153                                                                                                                                                                                                           153
154                    7F.                      , 999,999,999.00,           0 0        7S.                  ,                 999,999,999.00,                                                             0 0 154
155                                                                                                                                                                                                           155
156            8.  Interest income from Form 1040 or 1040-SR, line 2b.                                                                                                                                        156
157                                                                                                                                                                                                           157
158                                                                                                                                                                                                           158
159                    8F.                      , 999,999,999.00,           0 0        8S.                  ,                 999,999,999.00,                                                             0 0 159
160                                                                                                                                                                                                           160
161            9.  Dividend income from Form 1040 or 1040-SR, line 3b.                                                                                                                                        161
162                                                                                                                                                                                                           162
163                                                                                                                                                                                                           163
164                    9F.                      , 999,999,999.00,           0 0        9S.                  ,                 999,999,999.00,                                                             0 0 164
165                                                                                                                                                                                                           165
166           10.  State and local income tax refunds from federal Schedule 1, line 1.                                                                                                                        166
167                                                                                                                                                                                                           167
168                                                                                                                                                                                                           168
169                    10F.                     , 999,999,999.00,           0 0        10S.                 ,                 999,999,999.00,                                                             0 0 169
170                                                                                                                                                                                                           170
171           11.  Alimony received from federal Schedule 1, line 2a.                                                                                                                                         171
172                                                                                                                                                                                                           172
173                                                                                                                                                                                                           173
174                    11F.                     , 999,999,999.00,           0 0        11S.                 ,                 999,999,999.00,                                                             0 0 174
175                                                                                                                                                                                                           175
176           12.  Business income or loss from federal Schedule 1, line 3.                                                                                                                                   176
177                                                                                                                                                                                                           177
178                                                                                                                                                                                                           178
179                    12F.                     , 999,999,999.00,           0 0        12S.                 ,                 999,999,999.00,                                                             0 0 179
180                                                                                                                                                                                                           180
181           13.  Capital gain or loss from Form 1040 or 1040-SR, line 7.                                                                                                                                    181
182                                                                                                                                                                                                           182
183                                                                                                                                                                                                           183
184                    13F.                     , 999,999,999.00,           0 0        13S.                 ,                 999,999,999.00,                                                             0 0 184
185                                                                                                                                                                                                           185
186           14.  Other gains or losses from federal Schedule 1, line 4.                                                                                                                                     186
187                                                                                                                                                                                                           187
188                                                                                                                                                                                                           188
189                    14F.                     , 999,999,999.00,           0 0        14S.                 ,                 999,999,999.00,                                                             0 0 189
190                                                                                                                                                                                                           190
191                                                                                                                                                                                                           191
192                                                                                                                                                                                                           192
193                                                                                                                                                                                                           193
194                                                                                                                                                                                                           194
                       150-101-055
195                    (Rev. 09-12-22, ver. 01)                                                             00612201030000                                                                                    195
196                                                                                                                                                                                                           196
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198                                                                                                                                                                                                           198

199                                                                                                                                                                 199
  1  2   200   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   200   84 85
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201                                                                                                                                                                 201
202                                                                                                                                                                 202
                                                                                                      Oregon Department of Revenue
203                    2022 Form OR-40-P                                                                                                                            203
204                                                                                                                                                                 204
205                                                                                                                                                                 205
206                    Page 4 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.     206
207          Last name                                                                            SSN                                                               207
208                                                                                                                                                                 208
209                                                                                                                                                                 209
210          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                     999-99-9999                                                       210
211          Note: Reprint page 1 if you make changes to this page.                                                                                                 211
212                                               Federal column (F)                                    Oregon column (S)                                           212
213           15.  IRA distributions from Form 1040 or 1040-SR, line 4b.                                                                                            213
214                                                                                                                                                                 214
215                                                                                                                                                                 215
216                    15F.                     ,        999,999,999.00,          0 0 15S.            ,       999,999,999.00,                                   0 0 216
217                                                                                                                                                                 217
218           16.  Pensions and annuities from Form 1040 or 1040-SR, line 5b.                                                                                       218
219                                                                                                                                                                 219
220                                                                                                                                                                 220
221                    16F.                     ,        999,999,999.00,          0 0 16S.            ,       999,999,999.00,                                   0 0 221
222                                                                                                                                                                 222
223           17.  Schedule E income or loss from federal Schedule 1, line 5.                                                                                       223
224                                                                                                                                                                 224
225                                                                                                                                                                 225
226                    17F.                     ,        999,999,999.00,          0 0 17S.            ,       999,999,999.00,                                   0 0 226
227                                                                                                                                                                 227
228           18.  Farm income or loss from federal Schedule 1, line 6.                                                                                             228
229                                                                                                                                                                 229
230                                                                                                                                                                 230
231                    18F.                     ,        999,999,999.00,          0 0 18S.            ,       999,999,999.00,                                   0 0 231
232                                                                                                                                                                 232
233           19.  Social Security benefits from Form 1040 or 1040-SR, line 6b; and unemployment and other income from federal Schedule 1, lines 7 and 9.           233
234                                                                                                                                                                 234
235                                                                                                                                                                 235
236                    19F.                     ,        999,999,999.00,          0 0 19S.            ,       999,999,999.00,                                   0 0 236
237                                                                                                                                                                 237
238           20.  Total income. Add lines 7 through 19.                                                                                                            238
239                                                                                                                                                                 239
240                                                                                                                                                                 240
241                    20F.                     ,        999,999,999.00,          0 0 20S.            ,       999,999,999.00,                                   0 0 241
242                                                                                                                                                                 242
243          Adjustments                                                                                                                                            243
244           21.  IRA or SEP and SIMPLE contributions, from federal Schedule 1, lines 16 and 20.                                                                   244
245                                                                                                                                                                 245
246                                                                                                                                                                 246
247                    21F.                     ,        999,999,999.00,          0 0 21S.            ,       999,999,999.00,                                   0 0 247
248                                                                                                                                                                 248
249           22.  Education deductions from federal Schedule 1, lines 11 and 21.                                                                                   249
250                                                                                                                                                                 250
251                                                                                                                                                                 251
252                    22F.                     ,        999,999,999.00,          0 0 22S.            ,       999,999,999.00,                                   0 0 252
253                                                                                                                                                                 253
254                                                                                                                                                                 254
255                                                                                                                                                                 255
256                                                                                                                                                                 256
257                                                                                                                                                                 257
258                                                                                                                                                                 258
259                                                                                                                                                                 259
260                                                                                                                                                                 260
                       150-101-055
261                    (Rev. 09-12-22, ver. 01)                                                       00612201040000                                                261
262                                                                                                                                                                 262
  1  2   263   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   263   84 85
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264                                                                                                                                                                 264

265                                                                                                                                                                 265
  1  2   266   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   266   84 85
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267                                                                                                                                                                 267
268                                                                                                                                                                 268
                                                                                                       Oregon Department of Revenue
269                    2022 Form OR-40-P                                                                                                                            269
270                                                                                                                                                                 270
271                                                                                                                                                                 271
272                    Page 5 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.     272
273          Last name                                                                             SSN                                                              273
274                                                                                                                                                                 274
275                                                                                                                                                                 275
276          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                      999-99-9999                                                      276
277          Note: Reprint page 1 if you make changes to this page.                                                                                                 277
278          Adjustments (continued)              Federal column (F)                                     Oregon column (S)                                          278
279           23.  Moving expenses from federal Schedule 1, line 14.                                                                                                279
280                                                                                                                                                                 280
281                                                                                                                                                                 281
282                    23F.                     , 999,999,999.00,    0 0                      23S.     ,                        999,999,999.00,                 0 0 282
283                                                                                                                                                                 283
284           24.  Deduction for self-employment tax from federal Schedule 1, line 15.                                                                              284
285                                                                                                                                                                 285
286                                                                                                                                                                 286
287                    24F.                     , 999,999,999.00,    0 0                      24S.     ,                        999,999,999.00,                 0 0 287
288                                                                                                                                                                 288
289           25.  Self-employed health insurance deduction from federal Schedule 1, line 17.                                                                       289
290                                                                                                                                                                 290
291                                                                                                                                                                 291
292                    25F.                     , 999,999,999.00,    0 0                      25S.     ,                        999,999,999.00,                 0 0 292
293                                                                                                                                                                 293
294           26.  Alimony paid from federal Schedule 1, line 19a.                                                                                                  294
295                                                                                                                                                                 295
296                                                                                                                                                                 296
297                    26F.                     , 999,999,999.00,    0 0                      26S.     ,                        999,999,999.00,                 0 0 297
298                                                                                                                                                                 298
299           27.  Total adjustments from Schedule OR-ASC-NP, line A7 for the federal column and line A8 for the Oregon column.                                     299
300                                                                                                                                                                 300
301                                                                                                                                                                 301
302                    27F.                     , 999,999,999.00,    0 0                      27S.     ,                        999,999,999.00,                 0 0 302
303                                                                                                                                                                 303
304           28.  Total adjustments. Add lines 21 through 27.                                                                                                      304
305                                                                                                                                                                 305
306                                                                                                                                                                 306
307                    28F.                     , 999,999,999.00,    0 0                      28S.     ,                        999,999,999.00,                 0 0 307
308                                                                                                                                                                 308
309           29.  Income after adjustments. Line 20 minus line 28.                                                                                                 309
310                                                                                                                                                                 310
311                                                                                                                                                                 311
312                    29F.                     , 999,999,999.00,    0 0                      29S.     ,                        999,999,999.00,                 0 0 312
313                                                                                                                                                                 313
314          Additions                                                                                                                                              314
315           30.  Total additions from Schedule OR-ASC-NP, line B7 for the federal column and line B8 for the Oregon column.                                       315
316                                                                                                                                                                 316
317                                                                                                                                                                 317
318                    30F.                     , 999,999,999.00,    0 0                      30S.     ,                        999,999,999.00,                 0 0 318
319                                                                                                                                                                 319
320                                                                                                                                                                 320
321                                                                                                                                                                 321
322                                                                                                                                                                 322
323                                                                                                                                                                 323
324                                                                                                                                                                 324
325                                                                                                                                                                 325
326                                                                                                                                                                 326
                       150-101-055
327                    (Rev. 09-12-22, ver. 01)                                                        00612201050000                                               327
328                                                                                                                                                                 328
  1  2   329   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   329   84 85
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330                                                                                                                                                                 330

331                                                                                                                                                                                      331
  1  2   332   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   332   84 85
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333                                                                                                                                                                                      333
334                                                                                                                                                                                      334
                                                                                                                                                         Oregon Department of Revenue
335                        2022 Form OR-40-P                                                                                                                                             335
336                                                                                                                                                                                      336
337                                                                                                                                                                                      337
338                        Page 6 of 11  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                     338
339          Last name                                                                                                                        SSN                                        339
340                                                                                                                                                                                      340
341                                                                                                                                                                                      341
342          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                                                 999-99-9999                                342
343          Note: Reprint page 1 if you make changes to this page.                                                                                                                      343
344           Additions (continued)                    Federal column (F)                                                                                  Oregon column (S)             344
345           31.  Income after additions. Add lines 29 and 30.                                                                                                                          345
346                                                                                                                                                                                      346
347                                                                                                                                                                                      347
348                        31F.                     ,      999,999,999.00,            0 0                  31S.                                          , 999,999,999.00,           0 0 348
349                                                                                                                                                                                      349
350          Subtractions                                                                                                                                                                350
351           32.  Social Security and tier 1 Railroad Retirement Board benefits included on line 19F.                                                                                   351
352                                                                                                                                                                                      352
353                                                                                                                                                                                      353
354                        32F.                     ,      999,999,999.00,            0 0                                                                                                354
355                                                                                                                                                                                      355
356           33.  Total subtractions from Schedule OR-ASC-NP, line C7 for the federal column and line C8 for the Oregon column.                                                         356
357                                                                                                                                                                                      357
358                                                                                                                                                                                      358
359                        33F.                     ,      999,999,999.00,            0 0                  33S.                                          , 999,999,999.00,           0 0 359
360                                                                                                                                                                                      360
361           34.  Income after subtractions. Line 31 minus lines 32 and 33.                                                                                                             361
362                                                                                                                                                                                      362
363                                                                                                                                                                                      363
364                        34F.                     ,      999,999,999.00,            0 0                  34S.                                          , 999,999,999.00,           0 0 364
365                                                                                                                                                                                      365
366                                                                                                                                                                                      366
367            35.  Oregon percentage (see instructions; not more than 100.0%). ..................................................................................35.        999.9 %     367
368                                                                                                                                                                                      368
369          Deductions and modifications                                                                                                                                                369
370                                                                                                                                                                                      370
371            36.  Amount from line 34F ................................................................................................ 36.            , 999,999,999.00,           0 0 371
372                                                                                                                                                                                      372
373            37.  Oregon itemized deductions. Enter your Oregon itemized deductions from                                                                                               373
374                 Schedule OR-A, line 23. If you are not itemizing your deductions, enter 0 .............. 37.                                         , 999,999,999.00,           0 0 374
375                                                                                                                                                                                      375
376                                                                                                                                                                                      376
377            38.  Standard deduction. Enter your standard deduction ............................................. 38.                                  , 999,999,999.00,           0 0 377
378                                                                                                                                                                                      378
379                 You were:            38a.    X     65 or older          38b. X Blind  Your spouse was:                                    38c. X     65 or older  38d. X Blind       379
380                  Standard deductions                                                                                                                                                 380
381                            Single               Married filing jointly       Married filing separately Qualifying surviving spouse                     Head of Household             381
382                            $2,420                  $4,840                      $2,420 or $0                                                   $4,840              $3,895             382
383                  See instructions if you are age 65 or older, blind, or if someone can claim you as a dependent.                                                                     383
384                  See instructions if you are married filing separately.                                                                                                              384

385            39.   Enter the larger of line 37 or 38 ................................................................................. 39.             , 999,999,999.00,           0 0 385
386                                                                                                                                                                                      386
387                                                                                                                                                                                      387
388           40.  2022 federal tax liability (see instructions) .............................................................. 40.                      , 999,999,999.00,           0 0 388
389                                                                                                                                                                                      389
390                                                                                                                                                                                      390
391                                                                                                                                                                                      391
392                                                                                                                                                                                      392
                           150-101-055
393                        (Rev. 09-12-22, ver. 01)                                                                                                      00612201060000                  393
394                                                                                                                                                                                      394
  1  2   395   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   395   84 85
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396                                                                                                                                                                                      396

397                                                                                                                                                                                        397
  1  2   398   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   398   84 85
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399                                                                                                                                                                                        399
400                                                                                                                                                                                        400
                                                                                                                                                        Oregon Department of Revenue
401                       2022 Form OR-40-P                                                                                                                                                401
402                                                                                                                                                                                        402
403                                                                                                                                                                                        403
404                       Page 7 of 11  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                        404
405          Last name                                                                                                                              SSN                                    405
406                                                                                                                                                                                        406
407                                                                                                                                                                                        407
408          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                                                       999-99-9999                            408
409          Note: Reprint page 1 if you make changes to this page.                                                                                                                        409
410           Deductions and modifications (continued)                                                                                                                                     410
411                                                                                                                                                                                        411
412           41.  Total modifications from Schedule OR-ASC-NP, line D7 .......................................... 41.                                  ,              999,999,999.00, 0 0 412
413                                                                                                                                                                                        413
414                                                                                                                                                                                        414
415            42.  Add lines 39, 40, and 41 ........................................................................................... 42.            ,              999,999,999.00, 0 0 415
416                                                                                                                                                                                        416
417                                                                                                                                                                                        417
418            43.  Taxable income. Line 36 minus line 42. If line 42 is more than line 36, enter 0 ........ 43.                                        ,              999,999,999.00, 0 0 418
419                                                                                                                                                                                        419
420          Oregon tax                                                                                                                                                                    420
421            44.  Tax. Check the appropriate box if you’re using an alternative method to                                                                                                421
422                 calculate your tax (see instructions) .........................................................................  44.                ,              999,999,999.00, 0 0 422
423                                                                                                                                                                                        423
424              44a.   X       Schedule OR-FIA-40-P           44b.   X  Worksheet FCG              44c.                                        X   Schedule OR-PTE-PY                     424
425                                                                                                                                                                                        425
426            45.  Oregon income tax. Line 44 multiplied by the Oregon percentage                                                                                                         426
427                 from line 35 (see instructions) ..................................................................................  45.             ,              999,999,999.00, 0 0 427
428                                                                                                                                                                                        428
429                                                                                                                                                                                        429
430            46.  Interest on certain installment sales ......................................................................... 46.                 ,              999,999,999.00, 0 0 430
431                                                                                                                                                                                        431
432                                                                                                                                                                                        432
433            47.  Total tax before credits. Add lines 45 and 46 ........................................................... 47.                       ,              999,999,999.00, 0 0 433
434                                                                                                                                                                                        434
435          Standard and carryforward credits                                                                                                                                             435
436                                                                                                                                                                                        436
437            48.  Exemption credit (see instructions) ..........................................................................  48.                 ,              999,999,999.00, 0 0 437
438                                                                                                                                                                                        438
439                                                                                                                                                                                        439
440            49.  Total standard credits from Schedule OR-ASC-NP, line E16 ...................................  49.                                   ,              999,999,999.00, 0 0 440
441                                                                                                                                                                                        441
442                                                                                                                                                                                        442
443            50.  Total standard credits. Add lines 48 and 49 ............................................................  50.                       ,              999,999,999.00, 0 0 443
444                                                                                                                                                                                        444
445                                                                                                                                                                                        445
446            51.  Tax minus standard credits. Line 47 minus line 50. If line 50 is more than                                                                                             446
447                 line 47, enter 0 .........................................................................................................  51.     ,              999,999,999.00, 0 0 447
448                                                                                                                                                                                        448
449            52.  Total carryforward credits used this year from Schedule OR-ASC-NP, line F9.                                                                                            449
450                 Line 52 can’t be more than line 51 (see Schedule OR-ASC and                                                                                                            450
451                 OR-ASC-NP Instructions) ......................................................................................... 52.               ,              999,999,999.00, 0 0 451
452                                                                                                                                                                                        452
453                                                                                                                                                                                        453
454           53.  Tax after standard and carryforward credits. Line 51 minus line 52 ......................... 53.                                     ,              999,999,999.00, 0 0 454
455                                                                                                                                                                                        455
456                                                                                                                                                                                        456
457                                                                                                                                                                                        457
458                                                                                                                                                                                        458
                          150-101-055
459                       (Rev. 09-12-22, ver. 01)                                                                                                      00612201070000                     459
460                                                                                                                                                                                        460
  1  2   461   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   461   84 85
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462                                                                                                                                                                                        462

463                                                                                                                                                                                      463
  1  2   464   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   464   84 85
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465                                                                                                                                                                                      465
466                                                                                                                                                                                      466
                                                                                                                                                         Oregon Department of Revenue
467                         2022 Form OR-40-P                                                                                                                                            467
468                                                                                                                                                                                      468
469                                                                                                                                                                                      469
470                         Page 8 of 11   • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                   470
471          Last name                                                                                                                               SSN                                 471
472                                                                                                                                                                                      472
473                                                                                                                                                                                      473
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                                                        999-99-9999
474                                                                                                                                                                                      474
475          Note: Reprint page 1 if you make changes to this page.                                                                                                                      475
476           Standard and carryforward credits (continued)                                                                                                                              476
477                                                                                                                                                                                      477
478            54.   Total tax recaptures reported this year from Schedule OR-ASC-NP, line G5 ........... 54.                                            ,      999,999,999.00,      0 0 478
479                                                                                                                                                                                      479
480                                                                                                                                                                                      480
481            55.    Tax including tax recaptures. Line 53 plus line 54 ................................................... 55.                         ,      999,999,999.00,      0 0 481
482                                                                                                                                                                                      482
483          Payments and refundable credits                                                                                                                                             483
484                                                                                                                                                                                      484
485            56.  Oregon income tax withheld. Include a copy of your Forms W-2 and 1099 ........  56.                                                  ,      999,999,999.00,      0 0 485
486                                                                                                                                                                                      486
487                                                                                                                                                                                      487
488            57.  Amount applied from your prior year’s tax refund ...................................................  57.                            ,      999,999,999.00,      0 0 488
489                                                                                                                                                                                      489
490            58.  Estimated tax payments for 2022. Include all payments you made prior to the                                                                                          490
491                 filing date of this return, including real estate transactions. Do not include the                                                                                   491
492                 amount you already reported on line 57 ..................................................................  58.                       ,      999,999,999.00,      0 0 492
493                                                                                                                                                                                      493
494                                                                                                                                                                                      494
495            59.  Tax payments from a pass-through entity ...............................................................  59.                         ,      999,999,999.00,      0 0 495
496                                                                                                                                                                                      496
497                                                                                                                                                                                      497
498            60.  Earned income credit (see instructions) ...................................................................  60.                     ,      999,999,999.00,      0 0 498
499                                                                                                                                                                                      499
500            Reserved61.  Kicker (Oregon surplus credit). Enter your kicker credit amount (see instructions).                                                                          500
501                 If you elect to donate your kicker to the State School Fund, enter 0 and                                                                                             501
502                 see line 77 ...............................................................................................................  61.     ,      ,                    0 0 502
503                                                                                                                                                                                      503
504                                                                                                                                                                                      504
505            62.  Total refundable credits from Schedule OR-ASC-NP, line H7..................................  62.                                     ,      999,999,999.00,      0 0 505
506                                                                                                                                                                                      506
507                                                                                                                                                                                      507
508            63.  Total payments and refundable credits. Add lines 56 through 62 ...........................  63.                                      ,      999,999,999.00,      0 0 508
509                                                                                                                                                                                      509
510          Tax to pay or refund                                                                                                                                                        510
511            64.  Overpayment of tax. If line 55 is less than line 63, you overpaid.                                                                                                   511
512                 Line 63 minus line 55 ...............................................................................................  64.           ,      999,999,999.00,      0 0 512
513                                                                                                                                                                                      513
514            65.  Net tax. If line 55 is more than line 63, you have tax to pay.                                                                                                       514
515                 Line 55 minus line 63 ...............................................................................................  65.           ,      999,999,999.00,      0 0 515
516                                                                                                                                                                                      516
517                                                                                                                                                                                      517
518            66.  Penalty and interest for filing or paying late (see instructions) ................................  66.                              ,      999,999,999.00,      0 0 518
519                                                                                                                                                                                      519
520                                                                                                                                                                                      520
521                                                                                                                                                                                      521
522                                                                                                                                                                                      522
523                                                                                                                                                                                      523
524                                                                                                                                                                                      524
                            150-101-055
525                         (Rev. 09-12-22, ver. 01)                                                                                                     00612201080000                  525
526                                                                                                                                                                                      526
  1  2   527   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   527   84 85
3 4                                                                                                                                                                                      82 83
528                                                                                                                                                                                      528

529                                                                                                                                                                                            529
  1  2   530   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   530   84 85
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531                                                                                                                                                                                            531
532                                                                                                                                                                                            532
                                                                                                                                                               Oregon Department of Revenue
533                        2022 Form OR-40-P                                                                                                                                                   533
534                                                                                                                                                                                            534
535                                                                                                                                                                                            535
536                        Page 9 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                            536
537          Last name                                                                                                                                SSN                                      537
538                                                                                                                                                                                            538
539                                                                                                                                                                                            539
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                                                         999-99-9999
540                                                                                                                                                                                            540
541          Note: Reprint page 1 if you make changes to this page.                                                                                                                            541
542          Tax to pay or refund (continued)                                                                                                                                                  542
543            67.  Interest on underpayment of estimated tax. Include Form OR-10 ........................  67.                                                , 999,999,999.00,           0 0 543
544                                                                                                                                                                                            544
545                                                                                                                                                                                            545
546              Exception number from Form OR-10, line 1:  67a.                                9        Check box if you annualized:                     67b. X                               546
547                                                                                                                                                                                            547
548                                                                                                                                                                                            548
549            68.  Total penalty and interest due. Add lines 66 and 67 ................................................  68.                                  , 999,999,999.00,           0 0 549
550                                                                                                                                                                                            550
551            69.  Net tax including penalty and interest.                                                                                                                                    551
552                 Line 65 plus line 68. .................................................This is the amount you owe.69.                                      , 999,999,999.00,           0 0 552
553                                                                                                                                                                                            553
554            70.  Overpayment less penalty and interest.                                                                                                                                     554
555                 Line 64 minus line 68. ..............................................................This is your refund.70.                               , 999,999,999.00,           0 0 555
556                                                                                                                                                                                            556
557            71.  Estimated tax. Fill in the portion of line 70 you want applied to your open                                                                                                557
558                 estimated tax account .............................................................................................  71.                   , 999,999,999.00,           0 0 558
559                                                                                                                                                                                            559
560                                                                                                                                                                                            560
561            72.  Charitable checkoff donations from Schedule OR-DONATE, line 30 ....................... 72.                                                 , 999,999,999.00,           0 0 561
562                                                                                                                                                                                            562
563                                                                                                                                                                                            563
564            73.  Oregon 529 college savings plan deposits from Schedule OR-529, line 5 .............. 73.                                                   , 999,999,999.00,           0 0 564
565                                                                                                                                                                                            565
566            74.  Total. Add lines 71 through 73. The total can’t be more than your refund                                                                                                   566
567                 on line 70................................................................................................................... 74.          , 999,999,999.00,           0 0 567
568                                                                                                                                                                                            568
569                                                                                                                                                                                            569
570            75.  Net refund. Line 70 minus line 74 ....................................This is your net refund.75.                                          , 999,999,999.00,           0 0 570
571                                                                                                                                                                                            571
572                                                                                                                                                                                            572
573          Direct deposit                                                                                                                                                                    573
574            76.  For direct deposit of your refund, see instructions. Check the box if the final deposit destination is outside the United States:                         X                574
575                                                                                                                                                                                            575
576                 Type of account:                                                                                                                                                           576
577                                                    Account information:                                                                                                                    577
578                 X      Checking or                 Routing number                                                 Account number                                                           578
579                                                                                                                                                                                            579
580                 X      Savings                                                          999999999                 XXXXXXXXXXXXXXXXX                                                        580
581                                                                                                                                                                                            581
582          KickerReserveddonation                                                                                                                                                            582
583            77.  If you elect to donate your kicker to the State School Fund, check this box. .........  77a.                                                                               583
584                                                                                                                                                                                            584
585              Complete the kicker worksheet, located in the instructions, and enter the                                                                                                     585
586                 amount here. ...........................................................This election is irrevocable.  77b.                                , ,                         0 0 586
587                                                                                                                                                                                            587
588                                                                                                                                                                                            588
589                                                                                                                                                                                            589
590                                                                                                                                                                                            590
                           150-101-055
591                        (Rev. 09-12-22, ver. 01)                                                                                                            00612201090000                  591
592                                                                                                                                                                                            592
  1  2   593   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   593   84 85
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594                                                                                                                                                                                            594

595                                                                                                                                                                       595
  1  2   596   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   596   84 85
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597                                                                                                                                                                       597
598                                                                                                                                                                       598
                                                                                                                 Oregon Department of Revenue
599                     2022 Form OR-40-P                                                                                                                                 599
600                                                                                                                                                                       600
601                                                                                                                                                                       601
602                     Page 10 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.         602
603          Last name                                                                                SSN                                                                 603
604                                                                                                                                                                       604
605                                                                                                                                                                       605
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                         999-99-9999
606                                                                                                                                                                       606
607          Note: Reprint page 1 if you make changes to this page.                                                                                                       607
608          Sign here.  Under penalty of false swearing, I declare that the information in this return and any attachments is true, correct, and complete.               608
609            Your signature                                                                                                                                             609
610                                                                                                                                                                       610
611          X                                                                                                                                                            611
612          Date (MM/DD/YYYY)                                                                                                                                            612
613                                                                                                                                                                       613
614          99/99/9999/         /                                                                                                                                        614
615            Spouse signature                                                                                                                                           615
616                                                                                                                                                                       616
617          X                                                                                                                                                            617
618          Date (MM/DD/YYYY)                                                                                                                                            618
619                                                                                                                                                                       619
620          99/99/9999/         /                                                                                                                                        620
621            Signature of preparer other than taxpayer                                                                                                                  621
622                                                                                                                                                                       622
623          X                                                                                                                                                            623
624          Date (MM/DD/YYYY)                           Preparer phone                                          Preparer license number                                  624
625                                                                                                                                                                       625
626          99/99/9999/         /                       999-999-9999                                            XXXXXXXXXX                                               626
627          Preparer first name                            Initial     Preparer last name                                                                                627
628                                                                                                                                                                       628
629                                                                                                                                                                       629
             XXXXXXXXXXXXXXXX                               X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
630          Preparer address                                                                                                                                             630
631                                                                                                                                                                       631
632                                                                                                                                                                       632
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
633          City                                                                                          State ZIP code                                                 633
634                                                                                                                                                                       634
635                                                                                                                                                                       635
             XXXXXXXXXXXXXXXXXXXXXX                                                                        XX    XXXXX-XXXX
636          Signing this return does not grant your preparer the right to represent you or make decisions on your behalf. For more information, see the instructions for 636
637          the Tax Information Authorization and Power of Attorney for Representation form on our website.                                                              637
638                                                                                                                                                                       638
639          Important: Include a copy of your federal Form 1040, 1040-SR, 1040-X, or 1040-NR. We may adjust your return without it.                                      639
640                                                                                                                                                                       640
641          Pay the amount due (shown on line 69)                                                                                                                        641
642          • Online: www.oregon.gov/dor.                                                                                                                                642
643          • By mail: Payable to the Oregon Department of Revenue.Write “2022 Oregon Form OR-40-P” and the last four digits of your SSN or ITIN on your                 643
644            check or money order. If you include a payment with your return, don’t include Form OR-40-V payment voucher.                                               644
645                                                                                                                                                                       645
646          Mail your return                                                                                                                                             646
647          • Non-2-D barcode. If the large 2-D barcode box on the first page of this form is blank:                                                                     647
648            —  Mail tax-due returns to: Oregon Department of Revenue, PO Box 14555, Salem OR 97309-0940.                                                               648
649            —  Mail refund and no-tax-due returns to: Oregon Department of Revenue, PO Box 14700, Salem OR 97309-0930.                                                 649
650          • 2-D barcode. If the large 2-D barcode box on the first page of this form is filled in:                                                                     650
651            —  Mail tax-due returns to: Oregon Department of Revenue, PO Box 14720, Salem OR 97309-0463.                                                               651
652            —  Mail refund and no-tax-due returns to: Oregon Department of Revenue, PO Box 14710, Salem OR 97309-0460.                                                 652
653                                                                                                                                                                       653
654                                                                                                                                                                       654
655                                                                                                                                                                       655
656                                                                                                                                                                       656
                        150-101-055
657                     (Rev. 09-12-22, ver. 01)                                                                 00612201100000                                           657
658                                                                                                                                                                       658
  1  2   659   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   659   84 85
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660                                                                                                                                                                       660

661                                                                                                                                                               661
  1  2   662   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   662   84 85
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663                                                                                                                                                               663
664                                                                                                                                                               664
                                                                                    Oregon Department of Revenue
665                    2022 Form OR-40-P                                                                                                                          665
666                                                                                                                                                               666
667                                                                                                                                                               667
668                    Page 11 of 11 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.  668
669          Last name                                                          SSN                                                                               669
670                                                                                                                                                               670
671                                                                                                                                                               671
672          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   999-99-9999                                                                       672
673          Note: Reprint page 1 if you make changes to this page.                                                                                               673
674          Amended statement. Complete this section only if you’re amending your 2022 return or filing with a new SSN.                                          674
675                                                                                                                                                               675
676          If filing an amended return, use this space to explain what you’re changing. Include the return line numbers and the reason for each change. If your 676
677          filing status has changed, explain why. Include all supporting forms and schedules when you file your amended return, even if you haven’t changed    677
678          anything on them.                                                                                                                                    678
679                                                                                                                                                               679
680          If filing with a new SSN, enter your former identification number.                                                                                   680
681                                                                                                                                                               681
682                                                                                                                                                               682
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
683                                                                                                                                                               683
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684                                                                                                                                                               684
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685                                                                                                                                                               685
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686                                                                                                                                                               686
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687                                                                                                                                                               687
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
688                                                                                                                                                               688
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
689                                                                                                                                                               689
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
690                                                                                                                                                               690
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
691                                                                                                                                                               691
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
692                                                                                                                                                               692
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
693                                                                                                                                                               693
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
694                                                                                                                                                               694
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
695                                                                                                                                                               695
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
696                                                                                                                                                               696
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
697                                                                                                                                                               697
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
698                                                                                                                                                               698
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
699                                                                                                                                                               699
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                       150-101-055
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