Form 90r - Oregon Elderly Rental Assistance - 2014 Page 3

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Line instructions
Other income
Instructions are for lines not fully explained on
12. Department of Human Services (DHS) ben‑
efits. Fill in the total amount of public assis-
the form.
tance you received. Include amounts received
Note: You must round off cents to the nearest
from Seniors and People with Disabilities.
dollar. For example, $12.49 becomes $12.
Also include Temporary Assistance for Needy
Families (TANF). You should have received an
Work and investment income
Assistance Summary statement that shows the
amount you received. Don’t include:
Fill in the total amount received during the year.
• Special Shelter Allowance portion of TANF.
2. Interest and dividends. Fill in your total taxable
and nontaxable interest and dividends. Don’t
• Amounts for food stamps or surplus foods.
include “return of capital” dividends or insur-
• Payments for medical care, drugs, medical
ance policy “return of premium” dividends.
supplies, and services related to medical care
Note for lines 3, 4, and 6:
for which you received no direct payment.
• In-home services approved by the Oregon
• If you had a net loss, it is limited to $1,000.
Department of Human Services.
• Include income from part nerships and S
• Reimbursement of expenses from participat-
• Do not reduce these items by net operating loss
ing in work or training programs.
carryovers and carrybacks.
If you receive public assistance benefits for your
• Limit the combined total of your depreciation,
nursing home costs, include 23 percent of that
depletion, and amortization deductions to $5,000.
payment as public assistance income. Generally,
23 percent of the payment is rent plus utilities
5. Total gain on property sales. Fill in your total
and fuel (see “Special living places” on page 2).
gain from any property sales: stocks, bonds,
Don’t include payments to your nursing home
land, or other property. If you had a net loss,
for medical care, drugs, or medical supplies.
you can subtract up to $1,000. Don’t include any
gain you deferred or excluded from the sale of
14. Veteran’s and military benefits. Fill in your
your house.
total taxable and nontaxable veteran’s benefits,
GI Bill benefits, family allowances, and educa-
Retirement income
tional allowances.
15. Family support, gifts, and grants. Add all the
For each of the following, fill in the total amount
gifts, grants, and scholarships you received.
you received during the year.
Include any amounts you received from others
9. Social Security, Supplemental Security
to help pay your expenses. You can exclude up
Income (SSI), Social Security Disability
to $500 from household income. Don’t include
Insurance (SSDI), and railroad retirement.
federal grants to improve your home.
Fill in the total taxable and nontaxable Social
16. Other sources. See the household income
Security, SSI, SSDI, and Railroad Retirement
checklist on page 4.
Board benefits you received in 2014. Include
21. Household assets.
Social Security before any Medicare premium
deductions. Do not include reimbursed medical
Single or married/RDP—living apart. Com-
expenses. Include any amounts you received in
plete the household assets list on the back
your name from Social Security for the benefit
of your Form 90R. If the total value of your
of a minor child.
household assets is more than $25,000 you don’t
qualify for ERA.
10. Pensions and annuities. Fill in the total pen-
Married/RDP—living together. Complete the
sion and annuity income you received in 2014.
household assets list on the back of your Form
Federal pensions: Be sure to include your total
90R. If the total value of both your household
taxable and nontaxable pension income. Don’t
include your contribution to the plan. Include
lump-sum distributions and death benefits.
150-545-002 (Rev. 12-14)


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