Tax Compliance Certification (Attachment A} {2466a}

WH-193 Rev. 7/14 OREGON EMPLOYMENT DEPARTMENT TAX COMPLIANCE CERTIFICATION PART 1: TO BE COMPLETED BY APPLICANT Applicant Name (Last, First, Middle Initial): Check One: Owner Employee Social Security Number (SSN):* Business Name: 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)? No Yes (If yes, list names and EIN numbers): NAME: EIN: Address (Street, City, State, Zip Code): Daytime Telephone: FAX Number: Type of Business: (Check one for each applicant) Sole Proprietor Partnership Corporation Other (Specify) Did you have employees working for you in the past 12 months? No Yes Number: Do you expect to have employees working for you in the next 12 months? No Yes Number: MAILING ADDRESS Oregon Employment Department Attn: Tax Recover y 875 Union Street NE Salem, OR 97311 - 0030 Telephone: (503) 947 - 1488 FAX: (503) 947 - 1487 PART 2: THIS SECTION TO BE COMPLETED BY EMPLOYMENT DEPARTMENT STAFF ONLY YES NO $ AMOUNT Outstanding Liability Returns Filed: Payroll (Form OQ) Payroll (Form 132) Wage Detail Other (Specify) COMPLIANCE CERTIFICATION BY EMPLOYMENT DEPARTMENT: COMPLIANT NON - COMPLIANT Signature of ED Certifying Official DATE: *Privacy Act Statement: The submission of your social security number if voluntary. It will be used only for identification application process. American LegalNet, Inc. www.FormsWorkFlow.com