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Oregon Department of Revenue
5 Form OR-41-V 5
6 Oregon Fiduciary Income Tax Payment Voucher 6
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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 beginning (MM/DD/YYYY) Tax year ending (MM/DD/YYYY) 9
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11 99/99/9999/ / 99/99/9999/ / 11
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13 Trust or estate name on tax return 13
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
16 Executor or trustee name 16
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19 Federal employer identification number (FEIN) 19
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99-9999999
22 Address 22
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
25 City State ZIP code 25
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XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
28 Contact phone 28
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999-999-9999
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46 Want to make your payment online? Find options at www.oregon.gov/dor. Payment type (check one) 46
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48 Use this voucher only if you’re sending a payment separate from a return. Make Original return 48
49 your check, money order, or cashier’s check payable to the Oregon Department X 49
of Revenue. Write “Form OR-41-V,” the trust or estate name, FEIN, the tax year
50 beginning and ending dates, and a daytime phone on your payment. Don’t mail X Prepayment 50
51 cash. 51
52 Mail the voucher and payment to: X Amended return 52
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54 Oregon Department of Revenue 54
PO Box 14950
55 Salem OR 97309-0950 55
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57 Enter payment amount 57
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59 150-101-173 59
(Rev. 05-10-22, ver. 03)
60 9999 99 $ , 99,999,999.00, 0 0 60
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63 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 63
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