Form 90r - Oregon Elderly Rental Assistance - 2014 Page 7

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Clear Form
For department use only
Form
2014
90R
Date received
Oregon Elderly
Rental Assistance
You must fill in your date of birth in
order to receive assistance.
Last name
First name and initial
Enter your Social Security no. (SSN)
Date of birth (mm/dd/yyyy)
Spouse’s/RDP’s first name and initial
Enter spouse’s/RDP’s Social Security no.
Spouse’s/RDP’s last name if joint claim
Date of birth (mm/dd/yyyy)
Current mailing address
For department use only
1
2
3
City
State
ZIP code
Phone number
Work and investment income—Totals for the entire year
1 Wages, salaries, and other pay for work .................... 1
.00
2 Interest and dividends (total taxable and nontaxable)
2
...
.00
3 Business net income (loss limited to $1,000) ............. 3
.00
4 Farm net income (loss limited to $1,000) .................... 4
.00
5 Total gain on property sales (loss limited to $1,000) .. 5
.00
6 Rental net income (loss limited to $1,000) ................. 6
.00
7
Other income from your federal return. Identify
7
.00
8 Add lines 1 through 7 .........................................................................................
8
.00
Retirement income—Totals for the entire year
9 Social Security, supplemental security income (SSI),
railroad retirement (taxable and nontaxable) .........
9
.00
10 Pensions and annuities (see instructions) ..............
10
.00
11 Add lines 9 and 10 ............................................................................................. 11
.00
Other income—Totals for the entire year
12 DHS benefits (public assistance not including
food stamps) ..........................................................
12
.00
13 Unemployment benefits .........................................
13
.00
14 Veteran’s and military benefits .................................. 14
.00
15
15
Family support, gifts, and grants: Total received minus $500..
.00
16 Other sources: Identify
16
.00
17 Add lines 12 through 16 .................................................................................
17
.00
18 Add lines 8, 11, and 17 ............................................................................................................................. 18
.00
19 Adjustments to income from federal Form 1040, line 36 or federal Form 1040A, line 20 .....................
19
.00
20 Your total household income. Line 18 minus line 19. If your household income
is $10,000 or more, STOP HERE You don’t qualify for elderly rental assistance .................................
20
.00
21 Your total household assets. Fill in your total household assets from the
back of this form. (If you or your spouse/RDP are age 65 or older, the limitations do not
apply. Fill in -0- on line 21.) If your household assets exceed $25,000, STOP HERE
You don’t qualify for elderly rental assistance ..............................................
21
.00
Qualifying rent
22 Total Oregon rent you paid during 2014 (from box 7 of rent schedule on the back) .............................
22
.00
23 Special Shelter Allowance (see page 4) ..................................................................................................
23
.00
24 Total fuel and utilities only (not telephone). Don’t include rent (see page 1) .......................................
24
.00
25 Check the box if you paid rent to a:
nursing home
retirement/care home or facility
group home
Under penalties for false swearing, I declare that I have examined this claim, including accompanying schedules and statements. To the best of my
knowledge and belief it is true, correct, and complete. If prepared by a person other than the taxpayer, this declaration is based on all information
of which the preparer has any knowledge.
Date
Signature of preparer other than taxpayer
License no.
Your signature
X
Address
Sign
here
Date
Spouse’s/RDP’s signature
(If filing jointly, BOTH must sign)
State Zip code
City
X
Mail your completed 90R to: ERA claims, PO Box 14700, Salem OR 97309-0930
150-545-002 (Rev. 12-14)
Form 90R, page 1 of 2

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