FOR OFFICE USE ONLY OREGON e I O F Date Received TAX COMPLIANCE CERTIFICATION DEPARTMENT REVENUE • Please print using blue or black ink. • Return your completed form to the address below. PART 1—TO BE COMPLETED BY APPLICANT Applicant Name (Last, First, Middle Initial) Check one | Street Address Owner Social Security Number (SSN)* Employee City State ZIP Code Business Name Employer Identification Number (EIN) DBA (doing business as), If applicable Oregon Business Identification Number (BIN) Business Street Address City Business Daytime Telephone Number Type of Business (check one) State Fax Number Sole Proprietor ZIP Code Other Telephone Number Partnership Corporation Did you have employees working for you within the past 12 months? Yes Do you expect to have employees working for you within the next 12 months? Other (specify) No If yes, how many? __________________________ Yes No If yes, how many? _________________ Have you done business under any other business name(s) or employer identification number(s)? Name(s) Yes EIN(s) N o If yes, list below. ___________________________________________________ AUTHORIZATION ________________________________________________ I hereby authorize the Oregon Department of Revenue and its employees to disclose to_____DCBS/WCD/Worker Leasinq _______________ whether or not the applicant or entity named above has filed all required tax returns and/or whether the applicant or entity has paid all taxes due, which includes adherence to an acceptable payment plan. This authorization applies to the three tax years preceding and for any tax years subsequent to the date of this authorization. This authorization applies to the individual applicant and the business entity, including all business owners indicated above. This authorization remains in effect until 2 years from siqnature date ____________________ or until the Oregon Department of Revenue receives a notice of revocation from the taxpayer, whichever is sooner. This authorization is intended to designate the__Worker Leasing Program ________________________ to receive tax compliance information for the persons and tax years indicated. ORS 305.193, OAR 150-305.193. Signature Printed Name Date X Title (if applicable) Daytime Telephone Number PART 2—TO BE COMPLETED BY DEPARTMENT OF REVENUE STAFF ONLY Oregon Department of Revenue Tax Compliance Certification— Signature of Department of Revenue Certifying Official In Compliance. Title Not in Compliance. Date of Compliance Certification X Questions? Telephone: Fax to: 503-945-8735 Salem 503-378-4988 Toll-free within Oregon 1-800-356-4222 For general tax information: www.dor.state.or.us --or-- TTY (hearing or speech impaired; machine only): 503-945-8617 (Salem) or 1.800.886.7204 (toll-free within Oregon). Americans with Disabilities Act (ADA): This information is available In alternative formats. Call 503-378-4988 (Salem) or 1-800-356-4222 tollfree within Oregon). Asistencia en español. Llamo al 503-945-8618 en Salem o llame gratis al 1-800-356-4222 en Oregon Mail to: PTAC, Compliance & Filing Enforcement Oregon Department of Revenue 955 Center St NE Salem OR 97301-2555 *The submission or your Social Security number is voluntary. It will be used only for identification purposes to verify tax compliance as part of your application for a license, contract, or employment. Failure to provide it may result in a delay of the application and certification process. The statutory or other authority to request your Social Security number is provided by__________________________________ . 150-800-743 (5-04) Attachment B American LegalNet, Inc. www.USCourtForms.com