Form 150-101-024 - Credit For Home Care Of An Elderly Person - 1994
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2CREDIT FOR HOME CARE OF AN ELDERLY PERSON
Your Last Name
Your First Name & Initial (If joint return, also give spouse’s name and initial)
Your Social Security No.
—
—
Your Present Home Address
Spouse’s Social Security No.
—
—
GENERAL INSTRUCTIONS
The person you cared for must be certified by the Department of Human Resources. To do this, fill in Part I of this form. Send it to: Senior
and Disabled Services Division, Department of Human Resources, 500 Summer St. NE, Salem OR 97310-1015. The form will be returned
to you showing whether the elderly person is certified. If the elderly person is already certified, fill in Part II on the back of this form.
NOTE: To qualify for the credit, your household income must be less than $17,500 and the elderly person must have household
income of $7,500 or less.
PART I
The questions below are about the person you supported.
Social Security
1. Elderly person’s name ________________________________ Birthdate ________________ Number ______________________
2. Did the person stay in a nursing home or mental institution during the year?
YES
NO
If yes, list the dates ___________________________________________________________________
3. Did the person receive services from Oregon Project Independence during the year?
YES
NO
If yes, list the dates ___________________________________________________________________
4. Did the person receive any medical assistance from Adult and Family Services during the year?
YES
NO
If yes, list the dates ___________________________________________________________________
5. Check any of the seven conditions that existed for the elderly person during the year:
A. Problems with communication. These include severely limited vision, hearing, speaking, or ability to identify oneself to others.
B. Problems with mobility. These include having great difficulty in traveling inside or outside the home even with a cane, walker,
or wheelchair.
C. Problems with managing household and nutrition. These include having great difficulty in doing housekeeping, shopping,
or following a special diet.
D. Problems with maintaining personal independence or relationships. These include great difficulty in handling changes,
personal problems, and emotional situations. It also includes great difficulties with friends and living arrangements.
E. Problems with managing money. These include being unable to write checks, pay bills, or keep expenses within income.
F. Problems with health. These include severe medical problems requiring regular visits from a doctor or nurse. It also includes
being unable to take prescribed medicine.
G. Problems caring for oneself. These include great difficulty in bathing, dressing, or performing other bodily functions.
6. Based on the condition(s) you checked above, would the elderly person normally be placed in a nursing home?
YES
NO
If yes, during which months did the condition(s) exist? ________________________________________
X
I certify that the above questions were answered truthfully to the best of my knowledge.
______________________________________
Taxpayer’s Signature
Reason:
CERTIFIED:
Total tax year 19 _____
Not Certified
Partial tax year 19 _____
Authorized Signature
______________________________________
X
Dates:
150-101-024 (Rev. 10-94)
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