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150-610-172
Federal employer identification number (FEIN)
Business name
Quarter
Account number
Year (YYYY)
(Rev. 07-06-21, ver. 04)
Form OR-MT-V
Enter payment amount
$
Oregon Marijuana Tax Monthly Payment Voucher
Month of sales
Page 1 of 1
Oregon Department of Revenue
• Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.
Physical site address
City State ZIP code
Original return
Amended return
Estimated payment
Payment type (check one)
Make your check or money order payable to the Oregon Department of Revenue.
On your check or money order, write the following:
• Daytime phone number.
• Marijuana account number.
Mail your voucher with your payment to:
Oregon Department of Revenue
PO Box 14630
Salem OR 97309
Oregon Liquor and Cannabis Commission (OLCC) license number
Clear form
