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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 Schedule OR-21-MD
6                     Oregon Pass-through Entity Elective Tax Member Directory                                                                                                            6
7                                                                                                                                                                                         7
8                                                                                                                                                                                         8
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          PTE legal name                                                                                                                                                                10
11                                                                                                                                                                                        11
12                                                                                                                                                                                        12
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
13          Federal employer identification number (FEIN)                                                                                                                                 13
14                                                                                                                                                                                        14
15                                                                                                                                                                                        15
            99-9999999
16                                                                                                                                                                                        16
17          Part A :Member information                                                                                                                                                    17
18          List all members, including current address. Use additional pages as necessary.                                                                                               18
19          1a. PTE member legal name, if member is not an individual                                                                                                                     19
20                                                                                                                                                                                        20
21                                                                                                                                                                                        21
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22          1b. Ownership percentage                                                                                                                                                      22
23                                                                                                                                                                                        23
24                          999.9999 %                                                                                                                                                    24
25          1c. PTE contact first name                                1d. Initial 1e. PTE contact last name                                                                               25
26                                                                                                                                                                                        26
27                                                                                                                                                                                        27
            XXXXXXXXXXXXXXXX                                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
28          1f. Individual member first name                          1g. Initial 1h. Individual member last name                                                                         28
29                                                                                                                                                                                        29
30                                                                                                                                                                                        30
            XXXXXXXXXXXXXXXX                                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
31          1i. Member type                                           1j. Social Security number (SSN), if member is an individual           1k. FEIN, if member is not an individual     31
32                                                                                                                                                                                        32
33          X     Partnership   X      S corporation                  999-99-9999                                                            99-9999999                                   33
34                                                                                                                                                                                        34
35          X     Individual                                                                                                                                                              35
36                                                                                                                                                                                        36
37          1l. Current address                                                                                                                                                           37
38                                                                                                                                                                                        38
39                                                                                                                                                                                        39
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
40          1m. City                                                                                                               1n. State 1o. ZIP code                                 40
41                                                                                                                                                                                        41
42          XXXXXXXXXXXXXXXXXXXXXX                                                                                                 XX        XXXXX-XXXX -                                 42
43          1p. Phone                                                 1q. Form OR-OC (see instructions)                                                                                   43
44                                                                                                                                                                                        44
45                                                                                                                                                                                        45
            999-999-9999                                              X
46                                                                                                                                                                                        46
47                                                                                                                                                                                        47
48          1r.   Distributive proceeds .......................................................................................1r.           , 999,999,999.00,                        0 0 48
49                                                                                                                                                                                        49
50                                                                                                                                                                                        50
51          1s.   Addition for tax deducted at federal level ...................................................... 1s.                      , 999,999,999.00,                        0 0 51
52                                                                                                                                                                                        52
53                                                                                                                                                                                        53
54          1t.   Credit for PTE-E tax paid .................................................................................1t.             , 999,999,999.00,                        0 0 54
55                                                                                                                                                                                        55
56                                                                                                                                                                                        56
57                                                                                                                                                                                        57
58                                                                                                                                                        Continued on next page          58
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                      150-107-112
63                    (Rev. 09-13-22, ver. 01)                                                                                               22312201010000                               63
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69                                                                                                                                                                                         69
70                                                                                                                                                                                         70
71                       2022 Schedule OR-21-MD                                                                                               Oregon Department of Revenue                 71
72                       Oregon Pass-through Entity Elective Tax Member Directory                                                                                                          72
73                                                                                                                                                                                         73
74                                                                                                                                                                                         74
75                       Page 2 of 2    • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                        75
76           2a. PTE member legal name, if member is not an individual                                                                                                                     76
77                                                                                                                                                                                         77
78                                                                                                                                                                                         78
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
79           2b. Ownership percentage                                                                                                                                                      79
80                                                                                                                                                                                         80
81                           999.9999 %                                                                                                                                                    81
82           2c. PTE contact first name                                2d. Initial 2e. PTE contact last name                                                                               82
83                                                                                                                                                                                         83
84                                                                                                                                                                                         84
             XXXXXXXXXXXXXXXX                                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
85           2f. Individual member first name                          2g. Initial 2h. Individual member last name                                                                         85
86                                                                                                                                                                                         86
87                                                                                                                                                                                         87
             XXXXXXXXXXXXXXXX                                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
88           2i. Member type                                           2j. SSN if member is an individual                                     2k. FEIN, if member is not an individual     88
89                                                                                                                                                                                         89
90           X     Partnership      X   S corporation                  999-99-9999                                                            99-9999999                                   90
91                                                                                                                                                                                         91
92           X     Individual                                                                                                                                                              92
93                                                                                                                                                                                         93
94           2l. Current address                                                                                                                                                           94
95                                                                                                                                                                                         95
96                                                                                                                                                                                         96
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
97           2m. City                                                                                                               2n. State 2o. ZIP code                                 97
98                                                                                                                                                                                         98
99           XXXXXXXXXXXXXXXXXXXXXX                                                                                                 XX        XXXXX-XXXX -                                 99
100          2p. Phone                                                 2q. Form OR-OC (see instructions)                                                                                   100
101                                                                                                                                                                                        101
102                                                                                                                                                                                        102
             999-999-9999                                              X
103                                                                                                                                                                                        103
104                                                                                                                                                                                        104
105          2r.   Distributive proceeds .......................................................................................2r.           , 999,999,999.00,                        0 0 105
106                                                                                                                                                                                        106
107                                                                                                                                                                                        107
108          2s.   Addition for tax deducted at federal level ......................................................2s.                       , 999,999,999.00,                        0 0 108
109                                                                                                                                                                                        109
110                                                                                                                                                                                        110
111          2t.   Credit for PTE-E tax paid .................................................................................2t.             , 999,999,999.00,                        0 0 111
112                                                                                                                                                                                        112
113          Part B: Total distributive proceeds, addition, and credit                                                                                                                     113
114          Total the amounts in columns r, s, and t. If using more than one page, enter the totals on the first page only.                                                               114
115                                                                                                                                                                                        115
116          3.    Total distributive proceeds (column r) ...............................................................3.                   , 999,999,999.00,                        0 0 116
117                                                                                                                                                                                        117
118                                                                                                                                                                                        118
119          4.    Total addition for tax deducted at federal level (column s)................................4.                              , 999,999,999.00,                        0 0 119
120                                                                                                                                                                                        120
121                                                                                                                                                                                        121
122          5.    Total credit for PTE-E tax paid (column t) ..........................................................5.                    , 999,999,999.00,                        0 0 122
123                                                                                                                                                                                        123
124                                                    —Include this schedule when you file Form OR-21—                                                                                    124
125                                                                                                                                                                                        125
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                         150-107-112
129                      (Rev. 09-13-22, ver. 01)                                                                                             22312201020000                               129
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