1                                                                                                                                                                        1
  1  2   2    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   IMPORTANT! THIS FORM MUST BE FILED ELECTRONICALLY. Form All layers With grid &2 data  84 85
3 4                                                                                                                                                                      82 83
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-PT
6                      Pass Through of Distributive Share of Proceeds, Addition, and Credit                                                                              6
7                      For pass-through entities that are upper-tier members of electing entities                                                                        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          Use Schedule OR-21-MD-PT if you are a pass-through entity (PTE) that is an upper-tier member of a PTE that has made the election                             10
11          to pay Oregon’s PTE elective tax (PTE-E tax). This schedule is used to report your share of the electing PTE’s distributive proceeds,                        11
12          addition, and credit that you are passing through to your members.                                                                                           12
13                                                                                                                                                                       13
14          Complete a separate Schedule OR-21-MD-PT for each electing PTE of which you are an upper-tier member. Include the schedule(s)                                14
15          with Form OR-21. Be sure to mark the “Pass through” box on Form OR-21. See instructions for more information.                                                15
16                                                                                                                                                                       16
17          PTE legal name                                                                                                                                               17
18                                                                                                                                                                       18
19                                                                                                                                                                       19
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
20          Federal employer identification number (FEIN)                                                                                                                20
21                                                                                                                                                                       21
22                                                                                                                                                                       22
            99-9999999
23                                                                                                                                                                       23
24          Part A:Electing lower-tier entity information                                                                                                                24
25                                                                                                                                                                       25
26              X    Partnership   X       S corporation                                                                                                                 26
27                                                                                                                                                                       27
28          1a. Electing entity legal name                                                                                                                               28
29                                                                                                                                                                       29
30                                                                                                                                                                       30
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
31          1b. FEIN                                                                                                                                                     31
32                                                                                                                                                                       32
33                                                                                                                                                                       33
            99-9999999
34          1c. Current address                                                                                                                                          34
35                                                                                                                                                                       35
36                                                                                                                                                                       36
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
37          1d. City                                                                                        1e. State 1f. ZIP code                                       37
38                                                                                                                                                                       38
39          XXXXXXXXXXXXXXXXXXXXXX                                                                          XX        XXXXX-XXXX -                                       39
40                                                                                                                                                                       40
41                                                                                                                                                                       41
42          Part B: Distributive share of proceeds, addition, and credit from electing lower-tier entity                                                                 42
43                                                                                                                                                                       43
44          2.  Distributive proceeds from Schedule OR-21-K-1, line 1. ..................................2.           , 999,999,999.00,                        0 0       44
45                                                                                                                                                                       45
46                                                                                                                                                                       46
47          3.  Addition for tax deducted at federal level from Schedule OR-21-K-1, line 2. ...3.                     , 999,999,999.00,                        0 0       47
48                                                                                                                                                                       48
49                                                                                                                                                                       49
50          4.  Credit for PTE-E tax paid from Schedule OR-21-K-1, Line 3 ...........................4.               , 999,999,999.00,                        0 0       50
51                                                                                                                                                                       51
52                                                                                                                                                                       52
53                                                                                                                                                                       53
54                                                                                                                                                                       54
55                                                                                                                                                                       55
56                                                                                                                                                                       56
57                                                                                                                                 Continued on next page                57
58                                                        —Include this schedule when you file Form OR-21—                                                               58
59                                                                                                                                                                       59
60                                                                                                                                                                       60
61                                                                                                                                                                       61
62                                                                                                                                                                       62
                       150-107-110
63                     (Rev. 11-08-22, ver. 01)                                                                       22302201010000                                     63
64                                                                                                                                                                       64
  1  2   65   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   65                                                                                84 85
3 4                                                                                                                                                                      82 83
66                                                                                                                                                                       66

67                                                                                                                                                                 67
  1  2   68   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   68   84 85
3 4                                                                                                                                                                82 83
69                                                                                                                                                                 69
70                                                                                                                                                                 70
71                                                                                                                        Oregon Department of Revenue             71
                       2022 Schedule OR-21-MD-PT
72                                                                                                                                                                 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           Part C:Member information                                                                                                                             76
77           5a. Member first name                                         5b. Initial                                                                             77
78                                                                                                                                                                 78
79                                                                                                                                                                 79
             XXXXXXXXXXXXXXXX                                              X
80           5c. Member last name                                                                                                                                  80
81                                                                                                                                                                 81
82                                                                                                                                                                 82
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
83           5d. Current address                                                                                                                                   83
84                                                                                                                                                                 84
85                                                                                                                                                                 85
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
86           5e. City                                                                                           5f. State 5g. ZIP code                             86
87                                                                                                                                                                 87
88           XXXXXXXXXXXXXXXXXXXXXX                                                                             XX        XXXXX-XXXX -                             88
89           5h. Phone                                   5i. SSN                                                   5j. Ownership percentage 5k. Form OR-OC         89
90                                                                                                                                                                 90
91           999-999-9999                                999-99-9999                                                      999.9 %           X                      91
92                                                                                                                                                                 92
93                                                                                                                                                                 93
94           5l.   Member’s distributive proceeds from lower-tier entity....................................5l.           , 999,999,999.00,                    0 0 94
95                                                                                                                                                                 95
96                                                                                                                                                                 96
97           5m.  Member’s addition for tax deducted at federal level by lower-tier entity ......5m.                      , 999,999,999.00,                    0 0 97
98                                                                                                                                                                 98
99                                                                                                                                                                 99
100          5n.   Member’s credit for PTE-E tax paid by lower-tier entity ................................5n.            , 999,999,999.00,                    0 0 100
101                                                                                                                                                                101
102          6a. Member first name                                         6b. Initial                                                                             102
103                                                                                                                                                                103
104                                                                                                                                                                104
             XXXXXXXXXXXXXXXX                                              X
105          6c. Member last name                                                                                                                                  105
106                                                                                                                                                                106
107                                                                                                                                                                107
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
108          6d. Current address                                                                                                                                   108
109                                                                                                                                                                109
110                                                                                                                                                                110
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
111          6e. City                                                                                           6f. State 6g. ZIP code                             111
112                                                                                                                                                                112
113          XXXXXXXXXXXXXXXXXXXXXX                                                                             XX        XXXXX-XXXX -                             113
114          6h. Phone                                   6i. SSN                                                   6j. Ownership percentage 6k. Form OR-OC         114
115                                                                                                                                                                115
116          999-999-9999                                999-99-9999                                                      999.9 %           X                      116
117                                                                                                                                                                117
118                                                                                                                                                                118
119          6l.   Member’s distributive proceeds from lower-tier entity....................................6l.           , 999,999,999.00,                    0 0 119
120                                                                                                                                                                120
121                                                                                                                                                                121
122          6m.  Member’s addition for tax deducted at federal level by lower-tier entity ......6m.                      , 999,999,999.00,                    0 0 122
123                                                                                                                                                                123
124                                                                                                                                                                124
125          6n.   Member’s credit for PTE-E tax paid by lower-tier entity ................................6n.            , 999,999,999.00,                    0 0 125
126                                                                                                                                                                126
127                                                                                                                                                                127
128                                                                                                                                                                128
                       150-107-110
129                    (Rev. 11-08-22, ver. 01)                                                                           22302201020000                           129
130                                                                                                                                                                130
  1  2   131   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   131   84 85
3 4                                                                                                                                                                82 83
132                                                                                                                                                                132