Form 150-490-014 - Property Tax Deferral Application For 61 Or Younger And Disabled Or 62 Or Older - 2013 Page 2

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Applicant’s last name
First name and initial
Social Security number
–
–
Joint applicant’s last name
First name and initial
Social Security number
–
–
This section must be completed. List your yearly household income for 2012. Include income earned in other
states or countries. Your income el i gi bil i ty is determined by Oregon law (ORS 311.668). Your household income
must be less than $41,500 (taxable and non tax able in come) to qualify for the 2013–2014 property tax year.
Household income worksheet
00
1. Wages, salaries, and other pay for work (on federal Form 1040, line 7) ...... 1
2. Interest and dividends (total taxable and nontaxable)
00
(on federal Form 1040, line 9a) .................................................................... 2
00
3. Business net income (loss limited to $1,000) (on Form 1040, line 12) ........ 3
a. Do you have a business located on this property?
Yes
No
Percentage of property used for business purposes ______________%
00
4. Farm net income (loss limited to $1,000) (on Form 1040, line 18) ............... 4
Do you have a farm located on this property:
Yes
No
Percentage of property used for farm? __________________________%
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
Percentage of property used as a rental? _______________________%
7. Other capital gains (i.e., stocks and bonds (loss limited to $1,000)
00
(on federal Form 1040, line 13) .................................................................... 7
8. Total Social Security, Supplemental Security Income (SSI), and railroad
00
retirement before medicare premium deductions (on Form 1040, line 20a) ... 8
9. Pensions and annuities before health insurance premium
00
deductions. (total taxable and nontaxable) (on Form 1040, line 16a) .......... 9
00
10. Unemployment benefits (on federal Form 1040, line 19) ............................. 10
00
11. Child support ............................................................................................... 11
00
12. Veteran’s and military benefits ..................................................................... 12
00
13. Gambling winnings ...................................................................................... 13
00
14. All other sources. Identify: ______________________________________ ...... 14
00
15. Your total household income. Add lines 1-14 ............................................................................• 15
If your household income on line 15 is more than $41,500, STOP HERE. You do not qualify for the Deferral Program.
List the total net worth of all applicants. Net worth means the sum of the current market value of all assets includ-
ing real property, cash, savings accounts, bonds, and other investments after deducting outstanding liabilities.
Net worth doesn’t include the value of the property for which deferral is claimed, the cash value of life insurance
policies on the life of an applicant, or tangible personal property owned by an applicant (e.g., furniture, vehicles).
Asset worksheet ($500,000 limit, not including your home)
•
00
1. Cash, savings, and checking account balances as of Dec. 31, 2012 .......
1
2. Amount of investments in qualified retirement plans and
00
•
individual retirement accounts as of Dec. 31, 2012. ..................................
2
•
00
3. Net worth of investments as of Dec. 31, 2012 ..........................................
3
(Net worth means current value minus debt. Investments include real estate,
trust funds, stocks, stock options, bonds, other securities, commodities, etc.)
•
00
Your total assets. Add lines 1-3 .............................................................................................
4.
4
If your total assets on line 4 exceed $500,000, STOP HERE. You do not qualify for the Deferral Program.
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, cor-
rect, and complete (ORS 311.666-701). I understand a lien will be placed on this property and I will be charged lien recording and/
or security interest fees. I understand that 6 percent compound interest accrues on each years’ deferred tax amount (ORS.305.990).
Applicant’s signature
Date
Joint applicant’s signature
Date
X
X
150-490-014 (Rev. 12-12)
10
Property Tax Deferral for Disabled and Senior Citizens

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