Form Artx - Arts Tax Annual Household Exemption Form - 2013
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12013 Arts Tax Annual Household Exemption Form
For the year Jan. 1 - Dec. 31, 2013
Due: April 15, 2014
For Portland residents with a household income at or below the federal poverty guideline. A household includes all
residents within a dwelling included on a single federal or state tax return. Attach supporting documents (e.g.,
tax return and Food Stamp Award Letters) and any additional household members’ information.
2013 Portland home address (e.g., 111 SW Columbia St., #600) — No PO Boxes
Zip Code
Household phone number
Total number of people in the household
(adults and children on a single federal/state tax return)
Name (first, middle, last, suffix)
Social Security # (Last 4 #s) Birth year
Annual Income
$
Name (first, middle, last, suffix)
Social Security # (Last 4 #s) Birth year
Annual Income
$
Name (first, middle, last, suffix)
Social Security # (Last 4 #s) Birth year
Annual Income
$
Name (first, middle, last, suffix)
Social Security # (Last 4 #s) Birth year
Annual Income
$
If more than four (4) people in your household please attach additional sheet(s)
Total Annual Household Income
$
(Sum of all income for each
member of the household)
I understand that my exemption request is subject to verification and that I must provide verification
documents (e.g., federal tax return, food stamp, 2013 SNAP award letter, or 2013 Form 4506-T*) to support
the statements above. Failure to provide information to support your exemption request will result in denial.
Signature
Date
Email address
Phone (if different from above)
Send this form to: Revenue Bureau Arts Tax, PO Box 1278, Portland, OR 97207 | Online:
(or )
Instructions: Important 2013 Updates
Only complete this form if your annual household income is at or below the federal
2013 Poverty
poverty level (see chart). If your household income is above the federal poverty level,
Guideline
complete the Arts Tax Return (Form ARTS2013).
Persons in
Poverty
Enter all members of the household (adults and children) on lines 1 through 4 above.
Household
Guideline
Attach an additional page if there are more than four members of the household (all
residents within a dwelling included on a single federal or state tax return). Submit
1
$11,490
separate forms for people on different tax returns.
2
$15,510
Enter the total 2013 annual income for each household member. Income includes
all income earned or received from any source, regardless of whether it is taxable
3
$19,530
under state or federal law. Examples of income include interest from individual or
joint savings accounts or other interest bearing accounts, child support payments,
4
$23,550
alimony, disability income, unemployment assistance, sales of stocks and other
property (even if sold at a loss), dividends, social security income (taxable or non-
5
$27,570
taxable), gross receipts from a business and wages as an employee.
6
$31,590
You must provide verification documents in order for your exemption to be approved.
Please provide a signed copy of your 2013 federal Form 1040 (page 1 and 2). If you
7
$35,610
are unable to provide this return (for example, you are not subject to the Form 1040
8
$39,630
filing requirements), you can provide a copy of a public assistance award letter for
SNAP (Supplemental Nutrition Assistance Program) or TANF (Temporary Assistance
For households with more
for Needy Families) benefits. If you cannot provide any of these you must provide a
than 8 persons, add $4,020
*
completed 2013 federal Form 4506-T (record of account). You can print this form
for each additional person.
from our website (or ).
ARTX2013 (2/12/2014)
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