Form 150-303-086 - Disabled Veteran Or Surviving Spouse Exemption Claim - 2012 Page 2
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5B. I am an honorably discharged veteran who is certified by a licensed physician. You must file every year. Your total gross
income cannot be more than 185 percent of the annual federal poverty guidelines. See Part 1 of the instructions on page 3
of this form for more information.
1.
I have disabilities of 40 percent or more.
2.
I have attached my physician’s certificate and it is dated within one year of this claim.
3.
I have previously filed my disability certificate and do not need to file it now because I filed it after reaching the
age of 65 or I am certified permanently disabled.
4.
My total gross income received from all sources during the last calendar year is $ _____________________.
5.
Number of family members who are my dependents _____________.
Part 2—Claim for exemption by a surviving spouse or partner* of a qualifying veteran
ORS 307.250 grants an exemption to any qualified surviving spouse/partner of a veteran. To qualify, you cannot enter into
a new marriage or partnership. The deceased veteran must have been a member of and discharged or released under
honorable conditions from the U.S. Armed Forces and have completed a minimum period of active service. See Part 2 of
the instructions on page 4 of this form for more information.
Check the boxes that apply to you.
A. I am a surviving spouse/partner of a qualified veteran. You do not have to file every year. If any qualifying conditions
change, you must file a new claim to continue your exemption.
1.
I have not entered into a new marriage or partnership.
2.
The qualifying veteran died of service-connected injury or illness.
3.
The qualifying veteran received the maximum exemption for at least one year.
4.
My homestead was acquired after March 1 but prior to July 1 and the qualifying veteran died within 30 days of
the acquisition.
5.
I am a pensioned surviving spouse of an honorably discharged veteran of the Civil War or the Spanish War.
6.
I am filing for the first time.
7.
I have filed before in _________________ County.
Declaration
I declare under penalties of false swearing [ORS 305.990(4)] that I have examined this document and attachments, and to
the best of my knowledge, they are true, correct, and complete.
Signature of disabled veteran
Date
Telephone number
(
)
X
Signature of surviving spouse/partner
Date
Telephone number
(
)
X
* “Partner” means an individual joined in a domestic partnership and registered in Oregon under HB 2007, Oregon Laws 2007.
150-303-086 (Rev. 01-12)
Disabled Veteran or Surviving Spouse Exemption Claim (Page 2 of 5)
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