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Oregon Department of Revenue
5 Form OR-LTD-V 5
6 LTD Self-employment 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 First name (if filer is an individual) 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
22 Partnership name (if filer is a partnership) 22
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
25 Federal employer identification number (FEIN) 25
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99-9999999
28 Current mailing address 28
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
31 City State ZIP code 31
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XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
34 Contact phone 34
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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. X Original return 48
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Use this voucher only if you’re sending a payment separate from a return. Make
50 your check, money order, or cashier’s check payable to the Oregon Department X Prepayment 50
51 of Revenue. Write “Form OR-LTD-V,” the filer name, filer SSN or FEIN, the tax year 51
beginning and ending dates, and a daytime phone on your payment. Don’t mail
52 cash. Mail the voucher and payment to: X Amended return 52
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54 Oregon Department of Revenue 54
55 PO Box 14950 55
Salem OR 97309-0950
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57 Enter payment amount 57
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59 150-560-172 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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