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Tax Compliance Certification (Attachment A} 2466a - Oregon

Tax Compliance Certification (Attachment A} Form. This is a Oregon form and can be used in Worker Leasing Companies Workers Comp .
 Fillable pdf Last Modified 12/20/2006
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OREGON EMPLOYMENT DEPARTMENT TAX COMPLIANCE CERTIFICATION PART 1: TO BE COMPLETED BY APPLICANT Applicant Name (Last, First, Middle Initial): Social Security Number (SSN):* Check One: Owner Business Name: Employee Employer Identification Number (EIN): Oregon Business ID Number (BIN): DBA (Doing Business As), if applicable: Have you done business under any other business name or employer identification number (EIN)? (If yes, list names and EIN numbers): NAME: EIN: No Yes Address (Street, City, State, Zip Code): Daytime Telephone: FAX Number: MAILING ADDRESS Type of Business: (Check one for each applicant) Sole Proprietor Oregon Employment Department Partnership Attn: Tax Recovery Unit Corporation 875 Union Street NE Other (Specify) Salem, OR 97311-0030 Did you have employees working for you in the past 12 months? No Yes Number: Telephone: (503) 947-1540 Do you expect to have employees working for you in the next 12 FAX: (503) 947-1487 No Yes Number: months? PART 2: THIS SECTION TO BE COMPLETED BY EMPLOYMENT DEPARTMENT STAFF ONLY $ AMOUNT NO YES Outstanding Liability Returns Filed: Payroll (Form OQ) Payroll (Form 132) Wage Detail Other (Specify) COMPLIANCE CERTIFICATION BY EMPLOYMENT DEPARTMENT: COMPLIANT NON-COMPLIANT DATE: Signature of ED Certifying Official *Privacy Act Statement: The submission of your social security number is voluntary. It will be used only for identification purposes to facilitate your application for a worker leasing license or a farm labor contractor's license. Failure to provide it may result in a delay of the application process. Attachment A (09/03) American LegalNet, Inc. www.FormsWorkflow.com
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