Form Arts - Arts Income Tax Return - 2015

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YOU MAY FILE ONLINE, OVER THE PHONE, OR BY MAIL (See back of form for contact details.)
City of Portland
Revenue Division
Arts Income Tax Return
Arts Education and Access Fund
For the year January 1 to December 31, 2015
Due April 18, 2016
OFFICIAL USE ONLY
All adult Portland residents (18 years and older) are required to file an Arts Tax return.
Moved? Check and complete
Portland address that was the primary residence of the taxfilers for any portion of 2015.
Schedule B on back of form
Address (PO Box not allowed)
City
State
ZIP Code
OR
97__________
Does the household qualify for a household poverty exemption?
Yes (Complete Schedule A on back of form)
No
List everyone age 18 and older. (Only complete this section if you are NOT filing for a household poverty exemption.)
Name (first, middle, last, suffix)
Birth Year
$35 due
Annual taxable income less than $1,000
Email
Social Security Number
Name (first, middle, last, suffix)
Birth Year
$35 due
Email
Social Security Number
Annual taxable income less than $1,000
Name (first, middle, last, suffix)
Birth Year
$35 due
Email
Social Security Number
Annual taxable income less than $1,000
Name (first, middle, last, suffix)
Birth Year
$35 due
Email
Social Security Number
Annual taxable income less than $1,000
Name (first, middle, last, suffix)
Birth Year
$35 due
Email
Social Security Number
Annual taxable income less than $1,000
Calculate balance due. (Please note: penalties will be assessed if payment is not postmarked by April 18, 2016.)
Arts Tax
x $35 =
Balance
$
_____________ Check #: _____________
Total persons with $35 Due: _________
Total Amount Due:
Due
Sample amounts due: 1 person = $35; 2 people = $70; 3 people = $105; 4 people = $140
Make checks payable to “City of Portland”
Mailing address, if different from primary address in line
Address (PO Box allowed)
City
State
ZIP Code
Complete your information and mail this form with payment (if any) to the Revenue Division.
____________________________________
_______________
_________________________
Preparer name (printed)
Date
Daytime phone number
Mail to: Revenue Division Arts Tax, PO Box 2820, Portland OR 97208-2820
(See reverse for phone and online contact information.)
Disclosure of your Social Security number is required. This requirement is authorized under the Federal Privacy Act of 1974, the Tax Reform Act of 1976 and the Arts Tax
Administrative Rules. Your Social Security number will be used by the Revenue Division to assist in the administration of the Arts Tax including, but not limited to,
compliance with federal Form 1099 filing requirements and comparison of Arts Tax filings to federal taxfiler information.
ARTS2015 04/22/2016

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