Form 90r - Oregon Elderly Rental Assistance - 2012 Page 9

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Oregon
2012
Form
For department use only
90R
Elderly
Date received
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 last name if joint claim
Spouse’s/RDP’s first name and initial
Date of birth (mm/dd/yyyy)
Enter spouse’s/RDP’s Social Security no.
Current mailing address
For department use only
1
2
3
City
State
ZIP code
Telephone number
(
)
Work and investment income—Totals for the entire year
.00
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
Retirement income—Totals for the entire year
9 Social Security, supplemental security income (SSI),
.00
railroad retirement (taxable and nontaxable) ...................................• 9
.00
10 Pensions and annuities (see instructions) .......................................• 10
.00
11 Add lines 9 and 10 ............................................................................................................. 11
Other income—Totals for the entire year
12 Children, Adults, and Families (public assistance,
.00
not including food stamps) .............................................................. • 12
.00
13 Unemployment benefits ................................................................... • 13
.00
14 Veteran’s and military benefits .......................................................... 14
.00
15 Family support, gifts, and grants: Total received minus $500 ........ 15
.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
20 Your total household income. Line 18 minus line 19. If your household income
.00
is $10,000 or more, STOP HERE You don’t qualify for elderly rental assistance ......................................... • 20
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
.00
You don’t qualify for elderly rental assistance ................................................................ • 21
Qualifying rent
.00
22 Total Oregon rent you paid during 2012 (from box 7 of rent schedule on the back) ..................................... • 22
.00
23 Special Shelter Allowance (see page 3).......................................................................................................... • 23
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 declara-
tion is based on all information of which the preparer has any knowledge.
Sign
Your signature
Date
Signature of preparer other than taxpayer
License no.
here
Spouse’s/RDP’s signature (If filing jointly, BOTH must sign)
Address
Mail your completed 90R to: ERA claims, PO Box 14700, Salem OR 97309-0930
150-545-002 (Rev. 12-12)
Form 90R, page 1 of 2

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