Fillable Form 90r - Oregon Elderly Rental Assistance

Use Form 90R lines 1–19 to figure your household

10. Pensions and annuities. Fill in the total pen-

income. See pages 4-6 for a household income

sion and annuity income you received in 2012.

checklist.

Federal pensions: Be sure to include your total

taxable and nontaxable pension income. Don’t

Nonresidents and part‑year residents who lived in

include your contribution to the plan. Include

Oregon on December 31, 2012. Include all taxable

lump-sum distributions and death benefits.

and nontaxable income for the entire year. Include

income from sources inside and outside Oregon.

Other income

Line instructions

12. Children, Adults, and Families (CAF). Fill

in the total amount of public assistance you

Instructions are for lines not fully explained on

received. Include amounts received from

the form.

Seniors and People with Disabilities. Also

Note: You must round off cents to the nearest

include Temporary Assistance for Needy

Families (TANF). You should have received an

dollar. For example, $12.49 becomes $12.

Assistance Summary statement that shows the

Work and investment income

amount you received. Don’t include:

• Special Shelter Allowance portion of TANF.

Fill in the total amount received during the year.

2. Interest and dividends. Fill in your total taxable

• Amounts for food stamps or surplus foods.

and nontaxable interest and dividends. Don’t

• Payments for medical care, drugs, medical

include “return of capital” dividends or insur-

supplies, and services related to medical care

ance policy “return of premium” dividends.

for which you received no direct payment.

Note for lines 3, 4, and 6:

• In-home services approved by the Oregon

Department of Human Services.

• If you had a net loss, it is limited to $1,000.

• Include income from part nerships and S

• Reimbursement of expenses from participat-

corporations.

ing in work or training programs.

• Do not reduce these items by net operating loss

If you receive public assistance benefits for your

carryovers and carrybacks.

nursing home costs, include 23 percent of that

• Limit the combined total of your depreciation,

payment as public assistance income. Generally,

depletion, and amortization deductions to $5,000.

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

14. Veteran’s and military benefits. Fill in your

gain you deferred or excluded from the sale of

total taxable and nontaxable veteran’s benefits,

your house.

GI Bill benefits, family allowances, and educa-

tional allowances.

Retirement income

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

to help pay your expenses. You can exclude up

9. Social Security, Supplemental Security

to $500 from household income. Don’t include

Income (SSI), Social Security Disability

federal grants to improve your home.

Insurance (SSDI), and railroad retirement.

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 2012. Include

21. Household assets.

Social Security before any Medicare premium

deductions. Do not include reimbursed medical

Single or married—living apart. Complete the

expenses. Include any amounts you received in

household assets list on the back of your Form

your name from Social Security for the benefit

90R. If the total value of your household assets

is more than $25,000 you don’t qualify for ERA.

of a minor child.

150-545-002 (Rev. 12-12)

Form 90r - Oregon Elderly Rental Assistance - 2012 Page 3

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