2015 Application for Certification of Eligibility
Oregon Volunteer
EMS Provider Tax Credit - ORS 316.622
*
This form is electronic. If possible, please fill out as much on the computer as one can before printing and signing.
Applicant
Name: ___________________________________ E-mail: ___________________________________
(First, M.I., Last–please print legibly.)
(Please print legibly–this is how we send confirmations.)
Social Security Number: ______________________ Daytime Phone: (_____) _____ - __________
Home Mailing Address:
_______________________________________________________________________________________
Street Address
City
State
ZIP
EMT Status
1. Are you an Oregon certified Emergency Medical Services Provider?
£ Yes
£ No
(If you checked “No”, you are not eligible for this tax credit.)
2. How many hours during 2015 did you provide EMS Provider services in Oregon?
(Include all stand-by, response, and training
time.)
Paid Hours: _________ Volunteer Hours: _________
*A “volunteer” is a person properly trained under Oregon law who either operates an ambulance to and from the scene of an
emergency or renders emergency medical treatment on a volunteer basis so long as the total reimbursement received for such
volunteer services does not represent more than 25% of his or her gross annual income, not to exceed $3,000 per calendar year.
Primary Station/Agency
(Supervisor signature required below.)
Name: ___________________________________________________ Phone: (_____) _____ - _____________
________________________________________________________________________________________
Streeet Address
City
State
ZIP
Secondary Station/Agency
(If applicable.)
Name: ___________________________________________________ Phone: (_____) _____ - _____________
________________________________________________________________________________________
Streeet Address
City
State
ZIP
Tertiary Station/Agency
(If applicable.)
Name: ___________________________________________________ Phone: (_____) _____ - _____________
________________________________________________________________________________________
Streeet Address
City
State
ZIP
I attest that the information provided on this application is true and accurate:
________________________________________________________
Date: __________________________
Applicant Signature
Primary Agency EMS Provider Supervisor Name
: ____________________________________________
(please print)
Primary Agency EMS Provider Supervisor Signature: __________________________ Date: ____________________
Please either fax the 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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