Form Or-40-N - Oregon Income Tax Return For Nonresidents

Form Or-40-N - Oregon Income Tax Return For Nonresidents - 2016

2016 Form OR-40-N

Office use only

00541601010000

Page 1 of 5, 150-101-048 (Rev. 12-16)

Oregon Department of Revenue

Oregon Individual Income Tax Return for Nonresidents

Submit original form—do not submit photocopy

Space for 2-D barcode—do not write in box below

Fiscal year ending:

Amended return. If amending for an NOL,

tax year the NOL was generated:

Calculated using “as if” federal return.

Short year tax election.

Military.

Extension filed.

Employment exception.

Form OR-24.

First name and initial

Last name

Date of birth

Social Security no. (SSN)

(mm/dd/yyyy)

Applied

Deceased

–

for SSN

Spouse’s rst name and initial

Spouse’s last name

Spouse’s date of birth

Spouse’s SSN

Applied

Deceased

–

for SSN

Current mailing address

City

State

ZIP code

Country

Phone

(

)

–

Total

Filing status

Exemptions

(check only one box)

6a Credits for yourself:

Regular;

Severely disabled ...... 6a

Single.

Check box if someone else can claim you as a dependent.

Married filing jointly.

6b Credits for spouse:

Regular;

Severely disabled ...... 6b

Married filing separately (enter spouse’s information above).

Check box if someone else can claim your spouse as a dependent.

Head of household (with qualifying person).

Qualifying widow(er) with dependent child.

Dependents.

List your dependents in order from youngest to oldest. If more than four, check this box

and include Schedule OR-ADD-DEP

with your return.

Dependent’s date

Check if child with

First name

Last name

Code*

Dependent’s SSN

of birth (mm/dd/yyyy)

qualifying disability

–

*Dependent relationship code—Please see instructions to determine the appropriate code.

6c Total number of dependents ............................................................................................................................................................................ 6c

6d Total number of dependent children with a qualifying disability (see instructions) .......................................................................................... 6d

6e Total exemptions. Add 6a through 6d ......................................................................................................................................................Total 6e

Form Or-40-N - Oregon Income Tax Return For Nonresidents - 2016

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