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Oregon Department of Revenue
5 Form OR-40-V 5
6 Oregon Individual Income Tax Payment Voucher 6
7 7
8 Page 1 of 1 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. 8
9 Tax year begins (MM/DD/YYYY) Tax year ends (MM/DD/YYYY) For taxpayer use only: 9
10 Enter quarter (if making 10
an estimated payment)
11 99/99/9999/ / 99/99/9999/ / 9 11
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13 First name Initial 13
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XXXXXXXXXXXXXXXX X
16 Last name 16
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19 Social Security number (SSN) 19
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999-99-9999
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23 Spouse first name Initial 23
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XXXXXXXXXXXXXXXX X
26 Spouse last name 26
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
29 Spouse SSN 29
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999-99-9999
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33 Current mailing address 33
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
36 City State ZIP code 36
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XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
39 Contact phone 39
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999-999-9999
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46 Payment type (check one) 46
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48 Want to make your payment online? Find options at www.oregon.gov/dor. Original return 48
X
49 Use this voucher only if you are sending a payment separate from a return. For 49
50 more information, see Form OR-40-V Instructions. Make your check, money order, Estimated payment 50
51 or cashier’s check payable to the Oregon Department of Revenue. Write “Form X 51
OR-40-V,” your daytime phone, the last four digits of your SSN or ITIN, and the tax
52 year on your payment. Don’t mail cash. Mail the payment and voucher to: X Amended return 52
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54 Oregon Department of Revenue 54
PO Box 14950
55 Salem OR 97309-0950 55
56 56
57 Enter payment amount 57
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59 150-101-172 59
(Rev. 08-16-22, ver. 03)
60 9999 99 $ , 99,999,999.00, 0 0 60
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63 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 63
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