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Oregon Department of Revenue
5 Form OR-OTC-V 5
6 Oregon Combined Payroll 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
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10 Business identification number (BIN) Year (YYYY) Quarter that payroll was paid to employees (1, 2, 3, or 4) 10
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99999999-9 9999 9
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16 1. Unemployment Insurance ..................................................................................................1. , 99,999,999.99, 16
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19 2. State Withholding...............................................................................................................2. , 99,999,999.99, 19
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22 3. TriMet Transit District .........................................................................................................3. , 99,999,999.99, 22
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25 4. Lane Transit District ...........................................................................................................4. , 99,999,999.99, 25
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28 5. Workers’ Benefit Fund Assessment ...................................................................................5. , 99,999,999.99, 28
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31 6. Statewide Transit Tax .........................................................................................................6. , 99,999,999.99, 31
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34 7. Paid Leave Oregon ............................................................................................................7. , 99,999,999.99, 34
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36 Add lines 1–7 and enter total below 36
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38 Pay online at www.oregon.gov/dor or make check payable to: 38
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40 Oregon Department of Revenue 40
PO Box 14800
41 Salem OR 97309-0920 41
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
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XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
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57 Total payment (add lines 1–7 above) 57
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59 150-211-053 59
(Rev. 07-18-22, ver. 05)
60 9999 99 $ , 99,999,999.99, 60
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63 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 63
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