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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 all income for 2010. Include income earned in other states or countries.
Your income eligibility is determined by Oregon law (ORS 311.668). Your household income must be less than
$39,500 (taxable and nontaxable income) to qualify for the 2011–2012 property tax year.
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
Do you have a farm located on this property:
Yes
No
If yes, what 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
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 ($39,500 for 2010), 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 knowledge, they are
true, correct, and complete (ORS 311.666-701). I understand a lien will be placed on this property and I will be charged
lien recording fees. I understand that 6 percent simple interest accrues on each years’ deferred tax amount (ORS.305.990).
Applicant’s signature
Date
Joint applicant’s signature
Date
X
X
150-490-015 (Rev. 10-10)