Form 150-491-004 - Income Worksheet
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Revenue Use Only
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Date received
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INCOME WORKSHEET
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• Please print or type.
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Applicant’s last name
First name and initial
Social Security number
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–
–
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Joint applicant’s last name
First name and initial
Social Security number
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City
State
ZIP Code
Mailing Address
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List below all income for 2006. Include income earned in other states or countries. Your income eligibility is deter-
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mined by Oregon law. Your household income must be less than $36,500 (taxable and nontaxable income) to qualify.
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Income Worksheet
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Work and Investment Income
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00
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1. Wages, salaries, and other pay for work .................................................. 1
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2. Interest and dividends (total taxable and nontaxable) ............................. 2
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3. Business net income (loss limited to $1,000) ........................................... 3
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a. Do you have a business located on this property?
Yes
No
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If yes, explain type of business and percentage of property used for
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business purposes ___________________________________________
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4. Farm net income (loss limited to $1,000) ................................................. 4
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5. Total gain on property sales (loss limited to $1,000) ................................ 5
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6. Rental net income (loss limited to $1,000) ............................................... 6
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a. Is part of your home or property used as a rental?
Yes
No
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If yes, what percentage? ______________________________________
00
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7. Other capital gains (i.e., stocks and bonds (loss limited to $1,000) ........ 7
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8. Other income from your federal return. Identify:__________________ ..... 8
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9. Add lines 1 through 8 .................................................................................................................. 9
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Retirement Income
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10. Total Social Security, Supplemental Security Income (SSI),
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and railroad retirement ............................................................................. 10
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11. Pensions and annuities (total taxable and nontaxable) ............................ 11
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12. Add lines 10 and 11 .................................................................................................................. 12
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Other Income
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13. Unemployment benefits ........................................................................... 13
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14. Child support ........................................................................................... 14
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15. Support from others not in your household. Identify:______________ ..... 15
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16. Veteran’s and military benefits ................................................................. 16
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17. Gifts and grants. Total amount minus $500 ............................................ 17
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18. Gambling winnings................................................................................... 18
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19. Other sources. Identify: ____________________________________ .......... 19
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20. Add lines 13 through 19 ............................................................................................................ 20
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21. Your total household income. Add lines 9, 12, and 20 .......................................................... 21
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If the amount on line 21 is more than the household income limit allowed ($36,500 for 2006), you do not qualify
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for the Special Assessment Deferral.
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DECLARATION
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I declare under penalties for false swearing that I have examined all documents and to the best of my knowl-
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edge, they are true, correct, and complete. I understand a lien will be placed on this property. I understand that
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6 percent simple interest accrues on each years’ deferred bond amount.
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Applicant’s signature
Date
Joint applicant’s signature
Date
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X
X
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