Fillable Form 90r - Oregon Elderly Rental Assistance

Married/RDP—living together. Complete the

payment will be reduced by any TANF you

household assets list on the back of your Form

received in 2012.

90R. If the total value of both your household

Sign and mail Form 90R

assets combined is more than $25,000, you don’t

qualify for ERA. Include property you own

Before you mail Form 90R, check for the following:

together and separately.

9 Were you or your spouse/RDP age 58 or older on

Note: Examples of items not to include are: TVs,

December 31? Did you fill in your date of birth

VCRs, computers, cars, furniture, appliances,

and your spouse’s/RDP’s date of birth?

rings, and bicycles. (This is not intended to be a

9 Did you and your spouse/RDP sign and date

complete list.)

Form 90R?

9 Did you complete the entire form? An incomplete

Qualifying rent

claim could delay your assistance until next year.

22. Total Oregon rent you paid during 2012.

Remember—You must file Form 90R by July 1,

2013 so we can process and issue your payment in

Include all Oregon rent you paid for each resi-

November 2013.

dence you rented in 2012. Rent doesn’t include

advance rent or deposits for keys, cleaning, or

Have questions? Need help?

security. Keep your rent receipts for at least

three years.

General tax information .......

If the property you rented was partially exempt

Salem ...................................................... 503-378-4988

from property taxes, or you lived in a nursing

Toll-free from an Oregon prefix ...1-800-356-4222

home, retirement/rest home or center, group

home, or pay room and board, only a portion is

Asistencia en español:

qualifying rent. See “Special living places” on

En Salem o fuera de Oregon ........... 503-378-4988

page 2.

Gratis de prefijo de Oregon .........1-800-356-4222

TTY (hearing or speech impaired; machine only):

23. Special Shelter Allowance (TANF). Did you

Salem area or outside Oregon .........503-945-8617

receive TANF? If you did, the Assistance Sum-

Toll-free from an Oregon prefix ... 1-800-886-7204

mary statement you received shows the amount

of your TANF. Fill in the amount from the

Americans with Disabilities Act (ADA): Call one of

notice on this line. This allowance is an advance

the help numbers above for information in alterna-

payment of ERA and will reduce the amount of

tive formats.

your assistance.

Household income checklist

24. Fuel and utilities. Include the amount you

paid during 2012 for lights, water, garbage,

sewer, and heating while living in Oregon.

Use this list to decide if an item must be included

Don’t include amounts for telephone, cable, or

in total household income.

internet.

Alimony and separate maintenance .......... Yes

If the total of lines 22 and 24 is 20 percent or less

Annuities and pensions (reduced by

of your total household income on line 20, then

cost recovery) .................................................. Yes

you don’t qualify.

Business income (reduced by

If you lived in a nursing home, retirement/rest

expenses) (losses limited to $1,000) ............. Yes

home or center, group home, or paid room and

board, see “Special living places” on page 2.

Cafeteria plan benefits ........................................ No

25. Nursing home, retirement/care home or facil‑

Capital loss carryover .......................................... No

ity, or group home. Check the box that applies.

Capital losses (in year determined)

Generally, a nursing home provides medical

(losses limited to $1,000) ................................ Yes

care, but retirement/care homes or centers and

group homes don’t.

Child support ................................................. Yes

Child support included in

ERA payment. We will figure your assistance

amount for you. Remember your assistance

public assistance ............................................... Yes

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

Form 90r - Oregon Elderly Rental Assistance - 2012 Page 4

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