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              Form OQ/OA Amended
              Oregon Amended Payroll Tax Report

                                                                                         6522010123
Fax to:  503-947-1700   Mail to:  Oregon Department of Revenue, PO Box 14800, Salem OR 97309-0920                       Date received
To pay:  Complete Form OR-OTC-V and mail with your check, payable to Oregon Department of Revenue
Business name                                      Do not submit photocopies.

Federal employer identification number (FEIN)      Business identification number (BIN) Quarter/Year (Q/YY) changed

                                                                                        /
Reason for amending

                                              Corrected Amount            Original Reported Amount                      Net Change
State Withholding
 1.  Subject wages...................

 2.  Total tax amount................

 3.  Tax pre-paid this quarter ...

 4.  Total due ............................

Statewide Transit 
 5.  Subject wages...................

 6.  Total tax amount................

 7.  Tax pre-paid this quarter ...

 8.  Total due ............................

TriMet
 9.  Subject wages...................

  10. Total tax amount................

  11.   Tax pre-paid this quarter ...

  12. Total due ............................

Lane Transit District (LTD)
  13. Subject wages...................

  14. Total tax amount................

  15.  Tax pre-paid this quarter ...

  16. Total due ............................

                                              17a.  Corrected First Month 17b.  Corrected Second Month             17c.  Corrected Third Month
Monthly Summary of State 
Withholding Tax Liability

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150-206-522 (Rev. 08-18-22)                                                                                             Page 1 of 2

              Form OQ/OA Amended
              Oregon Amended Payroll Tax Report
              Business identification number (BIN) Quarter/Year (Q/YY)
                                                                                     6522020123
                                                   / /
Unemployment                               Corrected Amount           Original Reported Amount Net Change
Insurance (UI)
18.  Subject wages ...................

  19.  Excess wages ....................

20.  Taxable wages ...................

21. UI tax rate ..........................

22.  Total due ............................

Paid Leave
23.  Subject wages ...................

  24.  Excess wages ....................

25.  Taxable wages ...................

26. Paid Leave rate ..................

27. Employer contributions .....

28. Employee contributions .....

29.  Total due ............................
 Workers’ Benefit Fund  
(WBF) Assessment
 30.  Hours worked ....................

  31. WBF assessment rate ........

  32. Total assessment due .........

Number of UI workers 
33. First month ........................

  34. Second month ...................

35. Third month .......................
Number of Paid  
Leave employees 
36. Out-of-state employees ....

  37. Replacement workers........

Under penalty of false swearing, I declare that the information in this report and any enclosures are true, correct, and complete.
 Signature                                                                                     Date (MM/DD/YY)

X                                                                                              /              /
Preparer name                                                         Preparer phone           Preparer license number

150-206-522 (Rev. 08-18-22)                                                                                                       Page 2 of 2