Form 90r - Oregon Elderly Rental Assistance - 2012 Page 10
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10Rent schedule
List the places you rented in Oregon during 2012. 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 phone number
4. 2012 rental period
From:
To:
From:
To:
$
$
5. Rent you paid per month ............................. 5A
.....................................5B
$
$
6. Total rent you paid (per address) ................. 6A
.....................................6B
7. Total rent paid in 2012. Add boxes 6A and 6B and enter the total here.
$
Also enter this amount in box 22 on the front of this form ................................................................. 7
2012 household assets list
Use fair market value of your assets as of December 31, 2012. 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) ....................................................................
2. Personal property:
$
A. Money on hand: Currency, checks, 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. Value of shares of stock:
$
Capital, common, and preferred ...........................................................................................................
$
Shares in mutual funds and investment trusts or others (identify)
F. Value of assets or property used in a trade or business in which you or your spouse/RDP
$
have an ownership interest .........................................................................................................................
$
Total household assets. Fill in the total here and on line 21 on the front of this form ...............................
Form 90R, page 2 of 2
150-545-002 (Rev. 12-12)
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Parent category: Financial