Renewal Form Oregon Volunteer Ems Provider Tax Credit Certification - 2014
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1RENEWAL FORM
Oregon Volunteer EMS Provider 2014 Tax Credit Certification
This form is electronic. If possible, please fill out as much on the computer as one can before printing and signing.
EMS Provider
Station/Agency
Name: ___________________________________
(Complete only if applicable. Please print legibly.)
(First, M.I., Last - please print legibly.)
New Primary Station/Agency
Signature: _________________________________
Name: ______________________________________
E-mail: ___________________________________
Street: ______________________________________
(Please print legibly–this is how we send confirmations.)
City: _______________________________________
Last four numbers of S.S.: ________________
State: OR
Zip: ___________
Daytime Phone: (_____) _____ - __________
Phone: (_____) _____ - _____________
New mailing address as of 2014:
_________________________________________
EMS Provider Supervisor Printed Name:
Street Address
_________________________________________
___________________________________________
City
State
ZIP
EMS Provider Supervisor Signature:
Status
£ My Primary Station/Agency location (city) has not
___________________________________________
changed during 2014.
New Secondary Station/Agency
£ My Total Volunteer Hours have changed:
Paid Hours: _______ Volunteer Hours: ________
Name: ______________________________________
Street: ______________________________________
£ I retired as a volunteer EMS Provider on:
_________,2014.
City: _______________________________________
(Mo./Day)
£ I moved to a different state on _________,
State: OR
Zip: ___________
(Mo./Day)
Phone: (_____) _____ - _____________
2014 and no longer volunteer as an EMS Provider in
Oregon.
New Tertiary Station/Agency
£ I moved back to Oregon from a different state
on _________, 2014 and now volunteer. ß
Name: ______________________________________
(Mo./Day)
Street: ______________________________________
£ As of ________, 2014, I now volunteer in a
City: _______________________________________
(Mo./Day)
different city in Oregon. ß
State: OR
Zip: ___________
Phone: (_____) _____ - _____________
ß New Station/Agency information on the right is
required for these fields only.
Either fax completed form to (503) 494-4798 or mail to:
Oregon Office of Rural Health | 3181 SW Sam Jackson Park Rd., L-593 | Portland, OR 97239
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