Clear Form

                                                                   Registration Report
            Withholding on IRAs, Annuities, Compensation Plans, and Qualified Settlement Funds

• Required fields are in bold.
•  We can’t issue a business identification number (BIN) if your registration is incomplete.
•  You must fill in the date of first disbursement.
•  Please type or print. 
• Note: Use the Combined Employers Registration form if you need to establish a payroll account. 
Business name                                                                            Type of ownership (select one)
                                                                                              Pension and Annuity           Qualified Settlement Fund
                                                                                                        Date of disbursement  (this box must be completed)
                                                                                         Withholding    Month ________  Day ________  Year ________
                                                                                         Tax
                                                                                                        One-time distribution?
Federal identification number (FEIN)         Business phone
                                                                          Ext.                                         Yes                  No
Person at business authorized to discuss your account with us      Phone                                  Email
                                                                                              Ext.
Business mailing address                                                                                  FAX

City                                                                                                    State          ZIP code

Offsite payroll service, accountant, or bookkeeper

Contact person at the offsite payroll service, accountant, or bookkeeper Phone                            Email
                                                                                              Ext.
Mailing address for offsite payroll service (send:  forms   billings to this address?)
C/O
City                                                                                                    State          ZIP code

Bank reference / branch address

Identification of owners, partners, corporate officers, etc. (list additional owners on a separate sheet and attach to this form)
Social Security number*              Phone                                     Social Security number*                 Phone

Name                                                                           Name

Home address                                                                   Home address

City                                               State         ZIP code      City                                         State       ZIP code

Responsible for:          Filing tax returns        Paying taxes               Responsible for:    Filing tax returns   Paying taxes
                          Determining which creditors to pay first                                 Determining which creditors to pay first

Authorization
I certify the above statements to be true and correct. I authorize the Department of Revenue to verify any of the above information with regard to this 
business. I will notify the Department of Revenue if there is a change or cancellation of the above authorized representative.
Signature                                                          Date        Signature                                                   Date
X                                                                              X

Who must register:                                                                    Forms to be filed:
Payors of any IRAs, annuities, compensation plan distributions, or                    Form  OQ—Oregon  Quarterly  Combined  Tax  Report  (fill  out 
a qualified settlement to an individual.                                                       column B only on the OQ)
Need more information? Call 503-945-8100.                                             Form OR-WR—Oregon Annual Reconciliation Report
*As required by OAR 150-305-0010.
                                                                 Fax to: 503-947-1528 or Mail to: Oregon Employment Department 
                                                                                                  875 Union St NE Room 107
150-211-054 (Rev. 12-19)                                         Retain a copy for your records.  Salem, OR 97311