150-211-055 (Rev. 12-15)
Retain a copy for your records.
Combined Employer’s Registration
For agency use only
BIN
Business name
*
Assumed business name
Federal employer identication number (FEIN)
*
Contact person authorized to discuss your payroll account with us
Business telephone number
Ext.
Ext.
Business mailing address
E-mail address
Fax number
City
State ZIP code
Physical address where work is performed in Oregon
*
Employee home address
City
State ZIP code
Do you have any other locations in Oregon?
No
Yes, list additional locations on a separate sheet & attach to this form
Off site payroll service, accountant, or bookkeeper (attach Power of Attorney form)
Contact person at the off site payroll service, accountant, or bookkeeper
Mailing address for off site payroll service (send:
forms billings to this address?)
Telephone No.
City State ZIP code
C/O
Bank reference/branch address
Did you acquire/transfer all
Yes No or part Yes No of the Oregon business
operations of an ongoing business? How many employees transferred? _________________
Date of acquisition FEIN or BIN of acquired business
List acquired business name, previous owner, and telephone number
Identification of owners, partners, corporate officers, etc. (List additional owners on a separate sheet and attach to this form)
Social Security number
*
FEIN Telephone number
Name
Home address
City State ZIP code
Responsible for: Filing tax returns Paying taxes Hiring/ring
Determining which creditors to pay rst
Social Security number
*
FEIN Telephone number
Name
Home address
City State ZIP code
Responsible for: Filing tax returns Paying taxes Hiring/ring
Determining which creditors to pay rst
Authorization
I certify the above statements to be true and correct. I authorize the Employment Department, the Department of Revenue, and the Department of Consumer & Business
Services to verify any of the above information with regard to this business. I will notify each agency if there is a change or cancellation of the above authorized representative.
Signature Date
X
Signature
Fax to: 503-947-1528 or Mail to: Oregon Employment Department
875 Union St NE Rm 107
Salem OR 97311
Date
X
*
Must be lled in as required by
OAR 150-305.100.
See instructions below
You can register online with the Oregon Business Registry (OBR) at https://secure.sos.state.or.us/cbrmanager/
Type of ownership (check one):
Corporation LLC (Limited Liability Co.) Government–Local
Sub-chapter S Corp. recognized by IRS as a: Government–State
Sole Prop. (Individual) Corp, or Government–Federal
LLP (Limited Liability Part.) Individual (Sole Prop.), or Political Campaign
Partnership—General Partnership Other (describe below):
Partnership—Limited Non-prot 501(c)(3) ___________________
Pension and Annuity
(attach federal exemption)
___________________
Trust / Estate
Other Nonprot ___________________
Nature and principal products of your business (i.e., retail—men’s clothing;
services—janitorial; etc.). Be specic.
Type of return to be led (see instructions)
OQ (Oregon Quarterly) WA (Federal 943 lers only) OA (Domestic)
Enter number of employees (approximate)
LLC Member ______ Owner/Ofcer ______ Employees ______
Withholding
Tax
Transit
Tax
Unemployment
Tax
Workers’
Benefit Fund
Assessment
Must be
completed
Date employees were/will rst be paid for work in Oregon
*
Month _________ Day ________ Year _______________
Are employees working in these areas? (see instructions)
TriMet (Portland and surrounding metropolitan areas)
LTD (Eugene and Springeld areas)
Date employees rst paid for services performed within district(s)
TriMet __________________ LTD __________________
In what calendar quarter did/will your payroll rst exceed $1,000
or $20,000 agricultural labor? (see instructions)
Quarter ___________ Year_______________
Date rst Oregon employee was/will be hired
Month _________ Day ________ Year _______________
Agricultural Working on shing vessels Domestic (in-home workers)
Does any domestic worker request withholding?
Yes
No
Employees need to be covered by a workers’ compensation (WC) policy?
Recognized Indian Tribe
Check if any employees are: Courtesy Withholding
Yes
No, but I choose to have coverage
(Check the reason you don’t need a WC policy)
No, employees are covered by federal WC
No, only owners/corporate ofcers
No, other (explain) _______________________________________
Contact’s telephone number
Check here to authorize us to initiate e-mail exchange of tax information.
Clear Form
150-211-055 (Rev. 12-15)
Instructions for Combined Employers Registration
Transit taxes
TriMet tax is an employer-paid excise tax based on payrolls for
services performed in Multnomah and parts of Washington and
Clackamas counties. Please refer to the map in the Oregon Business
Guide.
LTD (Lane Transit District) covers the Eugene/Springfield area
of Lane county. This excise tax is based on the same principle as
TriMet. Please refer to the map in the Oregon Business Guide.
In-state and out-of-state employers who have employees working
in these districts are subject to these taxes. If your total business
activity is conducted outside of these areas, then you are not liable
for these taxes.
If your business is a nonprofit organization and you have employ-
ees working in these districts, you must send a copy of your 501(c)
(3) exemption with the completed registration as proof of exemp-
tion from transit taxes.
Need more information? Call 503-945-8091 or 503-378-4988. Or visit
our website at: www.oregon.gov/dor.
State unemployment tax
State unemployment tax is an employer paid tax that finances the
Oregon unemployment insurance program. Generally employers
must pay into the Unemployment Insurance Trust Fund if they:
Have one or more employees in each of 18 weeks during a cal-
endar year, or
Have total payroll of $1,000 or more in a calendar quarter (after
January 1, 2008).
Exceptions:
Agricultural labor is reportable if you have paid $20,000 or more
in total cash wages in a calendar quarter or have 10 or more em-
ployees during 20 weeks of a calendar year. You are considered to
be subject effective the beginning of that calendar year.
Agricultural employers subject to unemployment tax may choose
to file withholding quarterly.
Domestic/household service is subject if you have paid $1,000 or
more in total cash wages in a calendar quarter. You are considered
to be subject effective the beginning of that calendar year.
Partial transfers. If an employing enterprise sells, transfers, or ac-
quires all or part of a trade or business (including employees), such
transactions must be reported to the Employment Department, Tax
Section, within 60 days of the date the transaction becomes final.
Need more information? Call 503-947-1488. TTY (nonvoice) 503-
947-1495.
Workers’ Benefit Fund Assessment
This form doesn’t register you for workers’ compensation
insurance, which is mandatory for most employers. For
assistance determining subjectivity, call 503-947-7815 or visit:
www.cbs.state.or.us/wcd/communications/wcins.html.
This form registers you for the Workers’ Benefit Fund (WBF) assess-
ment. This fund benefits injured workers and employers helping
them return to work. Individuals subject to the WBF assessment are:
All paid workers for whom the employer is required to provide
workers’ compensation insurance coverage, and
All paid individuals (workers, owners, officers) who may oth-
erwise be nonsubject, but the employer chooses to cover under
workers’ compensation insurance.
All paid individuals performing personal support work who
are eligible for workers’ compensation insurance coverage
under HB 3618 (2010).
Need more information on WBF? Call 503-378-2372.
Who must register
Only individuals or firms with employees need to file a Combined
Employers Registration report. Corporate officers are considered
employees, including those in subchapter “S” corporations.
Note: The definition of “employee” differs among Oregon state
agencies. If you have questions, refer to the Oregon Business Guide
booklet or call the appropriate agency.
Other locations in Oregon
If you have more than one place of business in Oregon, on a sepa-
rate sheet, list each location. Attach the sheet to this registration
form.
Nature and principal products
Describe the nature of your business in Oregon and state the prin-
cipal products produced or activity (sales or service) performed.
If you are engaged in more than one activity, specify which is the
primary activity, product, or service.
If more space is needed, please write the information on a separate
sheet and attach it to this registration form.
Additional owner/officer information
List information on additional owners, partners, officers, etc., on a
separate sheet and attach it to this registration form.
Previous owner
If you acquired all or part of the business operations of the previous
owner, or if there was an entity change, mark “yes.”
If you acquired all or part of the previous business, but did not
assume any of the liabilities, mark “yes.” If the previous owner
retained any part of the business, mark “yes.”
On a separate sheet, describe the part of the business retained by
the previous owner. Attach the sheet to this registration form.
Withholding
Oregon law requires that all wages, salaries, commissions, bonuses,
fees, or other items of value paid to an individual for services as an
employee are subject to having Oregon tax withheld.
Courtesy withholding—is for an employer who has hired an Or-
egon resident that works outside of Oregon only.
Agricultural—is for employers who plant, cultivate or harvest
seasonal crops. These may include field/forage crops, seed of
grass, cereal grain, vegetable crops, flowers and others. This doesn’t
include livestock.
Domestic —withholding is not required for a domestic employee. If
your domestic employee has requested withholding and you have
agreed to withhold, mark the “yes’’ box on the front of this form
and file Form OA.
Employers file returns and pay withholding taxes based on their
federal filing requirements.
If you file federal form:
941, 941-M, or 945
File Oregon form: OQ–Oregon Quarterly Combined Tax Report
If you file federal form:
943
File Oregon form: *
WA–
Annual Withholding Tax Return for
Agricultural Employers.
*If you file Form 943 you may file Form WA or Form OQ. If you’re
also subject to state unemployment, Workers’ Benefit Fund Assess-
ment, or transit taxes, you must file a Form OQ quarterly.
Need more information? Call 503-945-8091 or 503-378-4988. Or visit
our website at: www.oregon.gov/dor.