Form 40f - Oregon Federal Retiree Verification Of Claim Form - 1998
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1Oregon
Form
For office use only
40F
Federal Retiree
Date received
Verification of Claim Form
Taxpayer’s name on tax return(s) filed for year(s) shown below
Social Security Number
Deceased
–
–
Spouse’s name on tax return(s) filed for year(s) shown below
Deceased
Social Security Number
–
–
Current Mailing Address (Check only one box) Address is for:
Both taxpayer and spouse
Taxpayer only
Spouse only
City
State
ZIP Code
Telephone Number
(
)
I am a surviving spouse, legal representative, or heir of the deceased person(s) shown above, and have
completed Form 243-F (on the back of this form).
1.
If all federal service is before October 1, 1991,
Taxpayer
Spouse
check this box and go to line 4. If some service is
.................
after October 1, 1991, complete all the boxes below
2.
Enter the number of months of federal
service worked before October 1, 1991
..................
3.
Enter the number of total months
of federal service worked
........................................
Enter federal pension included in Oregon
taxable income for each applicable tax year:
$
$
$
$
4.
Tax year
........................................................
1997
$
$
5.
Tax year
........................................................
1996
$
$
6.
Tax year
........................................................
1995
$
$
7.
Tax year
........................................................
1994
$
$
8.
Tax year
........................................................
1993
$
$
9.
Tax year
........................................................
1992
$
$
10.
Tax year
........................................................
1991
Under penalties for false swearing, I declare that I have examined this return, including accompanying schedules and statements, and
to the best of my knowledge and belief it is true, correct and complete. If prepared by a person other than taxpayer, this declaration is
based on all information of which the preparer has any knowledge.
Taxpayer’s signature
Date
SIGN
Signature of preparer other than taxpayer
License No.
HERE
Date
Current/Surviving spouse’s signature
150-101-120 (11-98)
Return this form to: Oregon Department of Revenue
PO Box 14600
Salem OR 97309-5049
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