Form Arts - Arts Income Tax Return - 2015 Page 2
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3SCHEDULE A: Household Poverty Exemption
(See Instructions)
Enter the annual income totals (from all sources) for each person in the household below,
2015 Federal Poverty
including children.
Guideline
Name
Annual Income
Age
SSN
Persons in
Poverty
Household
Guideline
-
-
1
$ ____________
1
$11,770
2
$15,930
-
-
3
$20,090
2
$ ____________
4
$24,250
-
-
5
$28,410
3
$ ____________
6
$32,570
-
-
7
$36,730
4
$ ____________
8
$40,890
For households with more
-
-
than 8 persons, add $4,160
5
$ ____________
for each additional person.
-
-
6
$ ____________
-
-
7
$ ____________
-
-
8
$ ____________
If there are more people in the household, attach an additional sheet with each
$ ____________
person’s name and age and enter the income total here:
$
Total annual household income:
Number of persons in household:
Don’t forget to complete lines ❺ and ❻ on the front of the form.
SCHEDULE B: Change of Address
(See Instructions)
Move Date
Name
Address
City
State
Zip Code
(mm/yy)
Check box if the new address entered above applies to all individuals listed as residing at this address.
If not, enter additional names and addresses below:
File by Mail: Revenue Division Arts Tax, PO Box 2820, Portland OR 97208-2820
File by Phone: (503) 865-4278
Fax: (503) 865-3065
TTY: (503) 823-6868
File Online: (or )
Physical address: Revenue Division, 111 SW Columbia Street, Suite 600, Portland, Oregon
Checks should be made payable to “City of Portland”
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