Subject Wages . . . . . . . .
Excess Wages . . . . . . . . .
Form OQ/OA - AMENDED Report
Taxable Wages . . . . . . .
Tax Rate (decimal). . . . .
Tax . . . . . . . . . . . . . . . . . . .
Original Amount
as Reported
Correct
Amount
Net
Change
Unemployment
Insurance (UI)
Original Amount
as Reported
Correct
Amount
Subject Wages . .
Tax . . . . . . . . . . . . .
Whole Hours Worked . .
Total Assessment Due . . .
Workers' Benefit
Fund (WBF)
TriMet Transit District
Original Amount
as Reported
Correct
Amount
Prepaid . . . . . . . . .
Total Tax Due . . .
Subject Wages . .
Tax . . . . . . . . . . . . .
Prepaid . . . . . . . . .
Total Tax Due . . .
Lane Transit District
Original Amount
as Reported
Correct
Amount
State Withholding
Original Amount
as Reported
Correct
Amount
Net
Change
Subject Wages . .
Tax . . . . . . . . . . . . .
Prepaid . . . . . . . . .
Total Tax Due . . .
Signature
Required X
Prepared By Date
/
WBF Rate (decimal). . . . . .
Preparer Telephone Number
I certify this report is true and correct and is filed under penalty of false swearing.
MAIL TO: OREGON DEPARTMENT OF REVENUE, PO BOX 14800, SALEM OR 97309-0920
MAKE CHECK PAYABLE TO: OREGON DEPARTMENT OF REVENUE and INCLUDE OTC
Monthly Summary
of State
Withholding
Correct Amount
for First Month (M1)
Correct Amount for
Second Month (M2)
Correct Amount
for Third Month (M3)
FAX TO: (503) 947-1700 OR
Reason for
Amended:
BUSINESS NAME:
Business Identification Number:
Federal Identification Number:
QTR/YR Changed:
Number of Workers
First Month. . . . . . . . . . . . . .
Third Month. . . . . . . . . . . . .
Second Month. . . . . . . . . . .
Original Amount
as Reported
Net
Change
Correct
Amount
REV 06/12
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