Form OR-ATAR Authorization to Apply Refund - Oregon

Form OR-ATAR or the "Authorization To Apply Refund" is a form issued by the Oregon Department of Revenue.

Download a fillable PDF version of the Form OR-ATAR down below or find it on the Oregon Department of Revenue Forms website.

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Clear form
Form OR-ATAR
Office use only
Date received
00880001010000
Page 1 of 1, 150-101-090 (Rev. 12-17)
Oregon Department of Revenue
Authorization to Apply Refund
Submit original form—do not submit photocopy
First name and initial
Last name
Social Security number
(SSN)
Spouse’s First name and initial
Spouse’s Last name
Spouse’s
SSN
Business name
Taxpayer identification number
I authorize the Oregon Department of Revenue to apply any refunds to any deficiencies determined for the tax program(s) and tax
year(s) listed below until the cease date specified. Refunds will continue to apply until the cease date below. If I don’t put a cease date,
refunds will continue to apply until the balance is paid in full.
I understand this authorization doesn’t affect my right to appeal the audit findings.
Tax program(s) refund applied to:
Tax year(s) refund applied to:
Cease date (date authorization to apply a refund ends):
/
/
Taxpayer’s signature
Date
X
/
/
Spouse’s signature
Date
(if a joint return was filed, both spouses must sign)
X
/
/
Address
Phone
(
)
City
State
ZIP code
Authorized representative
I certify that as a corporate officer, partner, fiduciary, or other qualified person, I have the authority to execute this authorization
on behalf of the taxpayer(s). The individual signing this form acknowledges notice of the following provision: Actions taken by a
designated representative are binding, even if the representative isn’t an attorney. Proceedings can’t later be declared legally defective
because the representative wasn’t an attorney.
Signature
Title
Date
/
/
X
Address
Phone
(
)
City
State
ZIP code
Return to:
_______________________
Department of Revenue
955 Center St NE
Salem OR 97301-2555
Clear form
Form OR-ATAR
Office use only
Date received
00880001010000
Page 1 of 1, 150-101-090 (Rev. 12-17)
Oregon Department of Revenue
Authorization to Apply Refund
Submit original form—do not submit photocopy
First name and initial
Last name
Social Security number
(SSN)
Spouse’s First name and initial
Spouse’s Last name
Spouse’s
SSN
Business name
Taxpayer identification number
I authorize the Oregon Department of Revenue to apply any refunds to any deficiencies determined for the tax program(s) and tax
year(s) listed below until the cease date specified. Refunds will continue to apply until the cease date below. If I don’t put a cease date,
refunds will continue to apply until the balance is paid in full.
I understand this authorization doesn’t affect my right to appeal the audit findings.
Tax program(s) refund applied to:
Tax year(s) refund applied to:
Cease date (date authorization to apply a refund ends):
/
/
Taxpayer’s signature
Date
X
/
/
Spouse’s signature
Date
(if a joint return was filed, both spouses must sign)
X
/
/
Address
Phone
(
)
City
State
ZIP code
Authorized representative
I certify that as a corporate officer, partner, fiduciary, or other qualified person, I have the authority to execute this authorization
on behalf of the taxpayer(s). The individual signing this form acknowledges notice of the following provision: Actions taken by a
designated representative are binding, even if the representative isn’t an attorney. Proceedings can’t later be declared legally defective
because the representative wasn’t an attorney.
Signature
Title
Date
/
/
X
Address
Phone
(
)
City
State
ZIP code
Return to:
_______________________
Department of Revenue
955 Center St NE
Salem OR 97301-2555

Download Form OR-ATAR Authorization to Apply Refund - Oregon

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