Form 150-490-015 - Property Tax Deferral Application For Disabled Citizens / Senior Citizens Page 2
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Page 2—Property Tax Deferral Application
Applicant’s Last Name
First Name and Initial
Social Security Number
Applicant’s Spouse/Other Joint Owner
First Name and Initial
Social Security Number
List below all income for 2003. Include income earned in other states or countries. Your income eligibility is
determined by Oregon law. Your household income must be less than $33,000 (taxable and nontaxable income)
to qualify for the 2004–2005 property tax year.
Income Worksheet
Read Me
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
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 home or property used as a rental?
Yes
No
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. Income of other joint owners (both taxable and nontaxable) ................
13
00
14. Adult and Family Services (welfare) .....................................................
14
00
15. Unemployment benefits ........................................................................
15
00
16. Child support ........................................................................................
16
00
17. Support from others not in your household. Identify:______________
17
00
18. Veteran’s and military benefits ..............................................................
18
00
19. Gifts and grants. Total amount minus $500 .........................................
19
00
20. Gambling winnings ...............................................................................
20
00
21. Other sources. Identify: ____________________________________
21
00
22. Add lines 13 through 21 ............................................................................................................ 22
00
23. Your total household income. Add lines 9, 12, and 22 .......................................................... 23
If the amount on line 23 is more than the household income limit allowed ($33,000 for 2003), you do not qualify
for either the Disabled Citizens’ or the Senior Citizens’ Property Tax Deferral.
DECLARATION
I declare under penalties for false swearing that I have examined all documents and to the best of my knowl-
edge, they are true, correct, and complete. I understand a lien will be place on this property and I will be charged
lien recording fees.
Your Signature
Date
Spouse/Joint Owner’s Signature
Date
X
X
150-490-015 (Rev. 9-03)
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