Form Arts - Arts Income Tax Return - 2016 Page 2
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3SCHEDULE A: Household Poverty Exemption
(See Instructions)
Enter the annual income totals (from all sources) for each person in the household below,
2016 Federal Poverty
including children.
Guideline
Persons in
Poverty
Name
Annual Income
Age
SSN
Household
Guideline
-
-
1
$11,880
1
$ ____________
2
$16,020
-
-
3
$20,160
2
$ ____________
4
$24,300
5
$28,440
-
-
6
$32,580
3
$ ____________
7
$36,730
-
-
8
$40,890
4
$ ____________
For households with more
-
-
than 8 persons, add $4,160
for each additional person.
5
$ ____________
-
-
6
$ ____________
-
-
7
$ ____________
-
-
8
$ ____________
If there are more people in the household, attach an additional sheet with each
$ ____________
person’s name and age and enter the income total here:
$
Total annual household income:
Number of persons in household:
OPTIONAL: By signing below, I hereby authorize release of my contact information and poverty exemption status to other governmental and
not-for-profit agencies for the purpose of qualifying for low income assistance.
(Complete signature line below.)
Signature
Printed Name
Phone Number
Email Address
Don’t forget to complete lines ❺ and ❻ on the front of the form.
SCHEDULE B: Change of Address
(See Instructions)
Move Date
Name
Address
City
State
Zip Code
(mm/yy)
File by Mail: Portland Revenue Division - Arts Tax, PO Box 2820, Portland OR 97208-2820
File by Phone: (503) 865-4278
Fax: (503) 865-3065
TTY: (503) 823-6868
File Online:
Physical address: Revenue Division, 111 SW Columbia Street, Suite 600, Portland, Oregon
Checks should be made payable to “City of Portland”
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