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3           A PRINTABLE COPY MAY BE PROVIDED FOR THE                                                                                                                                                   3
4           CUSTOMER'S RECORDS ONLY.                                                                                                                                                                   4
5                                                                                                                                                         Oregon Department of Revenue                 5
                  2022 Form OR-21-REF
6                 Oregon Pass-Through Entity Elective Tax Request for Refund                                                                                                                           6
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9                                                    Page 1 of 2 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.           9
10          Instructions: A pass-through entity (PTE) uses this form to request a refund of PTE elective tax (PTE-E tax) because estimated PTE-E                                                       10
11          tax payments were made by or on behalf of the PTE but the election will not be made.                                                                                                       11
12                                                                                                                                                                                                     12
13          A refund may be requested through the PTE’s Revenue Online account. Use this form only if you don’t have internet access.                                                                  13
14          Part A: PTE information                                                                                                                                                                    14
15          PTE legal name                                                                                                                                                                             15
16                                                                                                                                                                                                     16
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
18          Federal employer identification number (FEIN)                                                                                                                                              18
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            99-9999999
21          Current address                                                                                                                                                                            21
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
24          City                                                                                                                         State            ZIP code                                     24
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26          XXXXXXXXXXXXXXXXXXXXXX                                                                                                       XX               XXXXX-XXXX -                                 26
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28          Contact first name                                                                                 Initial                                                                                 28
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            XXXXXXXXXXXXXXXX                                                                                   X
31          Contact last name                                                                                                                                                                          31
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
34          Contact Phone                                                                                                                                                                              34
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            999-999-9999
37          Email                                                                                                                                                                                      37
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
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41          Part B: Payment information                                                                                                                                                                41
42          Enter all PTE-E tax payments made by or on behalf of the PTE. Use additional pages as needed.                                                                                              42
43          1a. Payment date (MM/DD/YYYY)                                                                                                1b. PTE-E tax payment amount                                  43
44                                                                                                                                                                                                     44
45          99/99/9999/        /                                                                                                                          ,        999,999,999.00,              0 0    45
46          2a. Payment date (MM/DD/YYYY)                                                                                                2b. PTE-E tax payment amount                                  46
47                                                                                                                                                                                                     47
48          99/99/9999/        /                                                                                                                          ,        999,999,999.00,              0 0    48
49          3a. Payment date (MM/DD/YYYY)                                                                                                3b. PTE-E tax payment amount                                  49
50                                                                                                                                                                                                     50
51          99/99/9999/        /                                                                                                                          ,        999,999,999.00,              0 0    51
52          4a. Payment date (MM/DD/YYYY)                                                                                                4b. PTE-E tax payment amount                                  52
53                                                                                                                                                                                                     53
54          99/99/9999/        /                                                                                                                          ,        999,999,999.00,              0 0    54
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                  150-107-116
63                (Rev. 09-13-22, ver. 01)                                                                                                                       22392201010000                        63
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5                                                                                                                                                                                                             Oregon Department of Revenue     5
                       2022 Form OR-21-REF
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9                                                    • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.Page 2 of 2                                                    9
10          Part B: continued                                                                                                                                                                                                                  10
11          Payment information                                                                                                                                                                                                                11
12          5. Total PTE-E tax payments. If using more than one page, enter the total of all                                                                                                                                                   12
13          payments on line 5 of the first page... ....................................................................5.                                                                                    , 999,999,999.00,            0 0 13
14                                                                                                                                                                                                                                             14
15          Part C - Signature and date                                                                                                                                                                                                        15
16          By signing this form, I declare under penalty of false swearing that the PTE will not be making the election to pay the PTE-E tax and is requesting a refund of payments                                                           16
17          made. I further declare that the information contained on this form and any attachment is true, correct, and complete.                                                                                                             17
18          Signature of general partner, officer, manager, or other authorized member                                                                                                                        Date (MM/DD/YYYY)                18
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20          X                                                                                                                                                                                                 99/99/9999/           /          20
21          First name                                                                                                                                                                      Initial Last name                                  21
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            XXXXXXXXXXXXXXXX                                                                                                                                                                X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
24          Title                                                                                                                                                                                                                              24
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            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
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30          Mail your completed form to:                                                                                                                                                                                                       30
31                                                                                                                                                                                                                                             31
            Oregon Department of Revenue
32                                                                                                                                                                                                                                             32
33          PO Box 14380                                                                                                                                                                                                                       33
34          Salem OR 97309-5075                                                                                                                                                                                                                34
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                       150-107-116
63                     (Rev. 09-13-22, ver. 01)                                                                                                                                                               22392201020000                   63
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