Form 150-491-646 - Application For Deferral Of Special Assessment On Senior Citizens' Residential Property - 2010 Page 2
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2Page 2—Special Assessment Deferral Application
Applicant’s last name
First name and initial
Social Security number
–
–
Joint applicant’s last name
First name and initial
Social Security number
–
–
List below all income for 2009. Include income earned in other states or countries. Your income eligibility is determined by
Oregon law (ORS 311.706). Your household income must be less than $38,500 (taxable and nontaxable income) to qualify.
Income Worksheet
Work and Investment Income
00
1. Wages, salaries, and other pay for work .................................................. 1
00
2. Interest and dividends (total taxable and nontaxable) ............................. 2
00
3. Business net income (loss limited to $1,000) ........................................... 3
a. Do you have a business located on this property?
Yes
No
If yes, explain type of business and percentage of property used for
business purposes ___________________________________________
00
4. Farm net income (loss limited to $1,000) ................................................. 4
00
5. Total gain on property sales (loss limited to $1,000) ................................ 5
00
6. Rental net income (loss limited to $1,000) ............................................... 6
a. Is part of your property used as a rental?
Yes
No
If yes, what percentage? ______________________________________
00
7. Other capital gains [i.e., stocks and bonds (loss limited to $1,000)] ....... 7
00
8. Other income from your federal return. Identify:__________________ ..... 8
00
9. Add lines 1 through 8 .................................................................................................................. 9
Retirement Income
10. Total Social Security, Supplemental Security Income (SSI),
00
and railroad retirement ............................................................................. 10
00
11. Pensions and annuities (total taxable and nontaxable) ............................ 11
00
12. Add lines 10 and 11 .................................................................................................................. 12
Other Income
00
13. Unemployment benefits ........................................................................... 13
00
14. Child support ........................................................................................... 14
00
15. Support from others not in your household. Identify:______________ ..... 15
00
16. Veteran’s and military benefits ................................................................. 16
00
17. Gifts and grants. Total amount minus $500 ............................................ 17
00
18. Gambling winnings................................................................................... 18
00
19. Other sources. Identify: ____________________________________ .......... 19
00
20. Add lines 13 through 19 ............................................................................................................ 20
00
21. Your total household income. Add lines 9, 12, and 20 .......................................................... 21
If the amount on line 21 is more than the household income limit allowed ($38,500 for 2009), you do not qualify
for the Special Assessment Deferral.
DECLARATION
I declare under penalties for false swearing that I have examined all documents and to the best of my knowledge,
they are true, correct, and complete (ORS 311.702-735). I understand a lien will be placed on this property. I
understand that 6 percent simple interest accrues on each years’ deferred installment amount (ORS 311.735).
Applicant’s signature
Date
Joint applicant’s signature
Date
X
X
150-491-646 (Rev. 08-10)
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