Page 2 — Form 90R — 2004
RENT SCHEDULE
List the places you rented in Oregon during 2004. Attach additional schedules if needed.
Residence A
Residence B
(if needed)
1. Your street address,
city, state, ZIP code
2. Full name of each
roommate
3. Landlord’s name,
street address, city,
state, ZIP code, and
telephone number
From:
To:
From:
To:
4. 2004 rental period
$
$
5. Rent you paid per month .............................. 5A
.....................................5B
$
$
6. Total rent you paid (per address).................. 6A
.....................................6B
7.
TOTAL RENT PAID IN 2004.
Add boxes 6A and 6B and enter the total here.
$
Also enter this amount in box 22 on the front of this form ................................................................... 7
2004 HOUSEHOLD ASSETS LIST
Use Fair Market Value of your assets as of December 31, 2004. If you or your spouse are age 65 or older, this list is not re quired.
$
1. Real property (includes fair market value of mobile home)......................................................................
2. Personal property:
$
A. Money on hand: Currency and bills of exchange or others (identify)__________________________
B. Money on deposit:
$
Checking and savings account..............................................................................................................
$
Certificates of deposit or others (identify)_______________________________________________
C. Funds on deposit:
$
Funds accruing due to death of the insured where withdrawal is at your option (insurance) ................
$
Funds accruing due to original maturity of a policy contract where withdrawal is at your option ..........
$
D. Money owed to you: Personal or business notes receivable or others (identify) _________________
E. Shares of stock:
$
Capital, common, and preferred ............................................................................................................
$
Shares in mutual funds and investment trusts or others (identify) ____________________________
$
F. Assets or property used in a trade or business in which you or your spouse have an ownership interest .
$
TOTAL HOUSEHOLD ASSETS.
Fill in the total here and on line 21 on the front of this form.......................
150-545-001 (Rev. 12-04) Web