Form 150-101-024 - Credit For Home Care Of A Person Age 60 Or Older

O R E G O N

D E PA R T M E N T

CREDIT FOR HOME CARE OF A PERSON AGE 60 OR OLDER

O F R E V E N U E

Your Last Name

Your First Name and Initial (if a 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 care for must be certified by the Department of Human Services. To do this, fill in Part I of this form. Send it to: Seniors

and People with Disabilities (formerly known as Senior and Disabled Services Division), Department of Human Services, 500 Summer St

NE, E02, Salem OR 97301-1073. The form will be returned to you showing whether the person you care for is certified. If the person you

care for 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 person you care for must have household income of $7,500 or less.

PART I

The questions below are about the person you care for.

1. Name ________________________________________ Birth date ______________ Social Security No. ___________________

2. Did the person stay in a nursing home, rehabilitation facility, or other long-term care facility during the year?

YES

If yes, list the dates _________________________________________________________________________

3. Did the person receive home care services from Oregon Project Independence during the year?

YES

If yes, list the dates _________________________________________________________________________

4. Did the person receive any medical assistance from Seniors and People with Disabilities during the year?

YES

If yes, list the dates _________________________________________________________________________

5. Check any of the seven conditions that existed, for the person you care for, 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 a household or 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 several medical problems requiring regular visits from a doctor or nurse. It also includes

being unable to take prescribed medicine.

G. Problems with personal care tasks. These include bathing, toileting, dressing, and feeding.

6. Based on the condition(s) you checked above, would the person you care for normally be placed in a nursing home?

YES

If yes, during which months did the condition(s) exist? _______________________________________________

I certify that the above questions were answered truthfully to the best of my knowledge. ____________________________________

Taxpayer’s Signature

For Official Department Use Only

Reason:

Total tax year 20 ______

CERTIFIED:

Not Certified

Partial tax year 20 _____

Authorized Signature

Dates: ___________________________________________

150-101-024 (Rev. 1-03) Web

Form 150-101-024 - Credit For Home Care Of A Person Age 60 Or Older - 2003

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