Rent schedule
List the places you rented in Oregon during 2014. Attach additional schedules if needed.
Residence A
Residence B
(if needed)
1. Your street address, city, state, ZIP code
Address
Address
City
State
Zip code
City
State
Zip code
2. Full name of each roommate
3. Landlord’s name, street address, city, state, ZIP code, and telephone
First name
Last name
First name
Last name
Address
Address
City
State
Zip code
City
State
Zip code
Phone
Phone
4. 2014 rental period
From:
To:
From:
To:
5A
............................... 5B
5. Rent you paid per month ............................
$
$
.00
.00
6A
............................... 6B
6. Total rent you paid (per address) ................
$
$
.00
.00
7. Total rent paid in 2014. Add boxes 6A and 6B and enter the total here.
.................................................................7
Also enter this amount in box 22 on the front of this form
$
.00
2014 household assets list
Use fair market value of your assets as of December 31, 2014. If you or your spouse/RDP are age 65 or older, this list is not required.
$
1. Real property (includes fair market value of mobile home) .....................................................................
.00
2. Personal property:
$
.00
A. Money on hand: Currency, checks, or others (identify)
B. Money on deposit:
$
Checking and savings account .............................................................................................................
.00
$
Certificates of deposit or others (identify)
.00
C. Funds on deposit:
$
Funds accruing due to death of the insured where withdrawal is at your option (insurance) ..............
.00
$
Funds accruing due to original maturity of a policy contract where withdrawal is at your option .......
.00
$
D. Money owed to you: Personal or business notes receivable or others (identify)
.00
E. Value of shares of stock:
$
Capital, common, and preferred ...........................................................................................................
.00
$
Shares in mutual funds and investment trusts or others (identify)
.00
F. Value of assets or property used in a trade or business in which you or your spouse/RDP
$
have an ownership interest ....................................................................................................................
.00
$
Total household assets. Fill in the total here and on line 21 on the front of this form ................................
.00
Form 90R, page 2 of 2
150-545-002 (Rev. 12-14)