Form 150-101-687 - Exempt Income Schedule For Enrolled Members Of A Federally Recognized American Indian Tribe
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Exempt Income Schedule for
For office use only
Date received
Enrolled Members of a Federally
Recognized American Indian Tribe
Your last name as shown on your tax return
First name and middle initial as shown on your tax return
Your Social Security number
Your street address
City
State
ZIP code
(not a PO Box)
Your tribal enrollment number
Your full name as shown on tribal enrollment
Indian tribe of which you are an enrolled member
Your tribal headquarter’s address
If you are filing a joint return and your spouse’s/RDP’s income meets the exempt income requirements, fill in the requested information below.
Spouse’s/RDP’s last name as shown on your tax return
Spouse’s/RDP’s first name and middle initial as on your tax return
Spouse’s/RDP’s Social Security number
Spouse’s/RDP’s street address
(not a PO Box)
City
State
ZIP code
Spouse’s/RDP’s full name as shown on tribal enrollment
Spouse’s/RDP’s tribal enrollment no.
Indian tribe of which spouse/RDP is an enrolled member
Spouse’s/RDP’s tribal headquarter’s address
You will not have to pay Oregon income tax on income that meets all of the following requirements:
• The income is earned by an enrolled member of a federally recognized American Indian tribe; and
• The income comes from sources within the boundaries of federally recognized Indian country in Oregon; and
• The enrolled member lived on federally recognized Indian country in Oregon when the income was earned.
YOUR EXEMPT INCOME INFORMATION
Street address, city, state, and
Employer’s name
Street address, city, state,
Income type (wages,
Amount
ZIP code where you worked
or source of
and ZIP code where you lived
interest, gambling
qualifying as
if wages, unemployment, or
exempt income
(not a PO Box)
winnings, etc.)
exempt income
retirement income
SPOUSE’S/RDP’S EXEMPT INCOME INFORMATION (if filing a joint return and income meets requirements)
Street address, city, state, and
Employer’s name
Street address, city, state,
Income type (wages,
Amount
ZIP code where you worked
Or source of
and ZIP code where you lived
interest, gambling
qualifying as
if wages, unemployment, or
winnings, etc.)
exempt income
(not a PO Box)
exempt income
retirement income
Total of your and/or your spouse’s/RDP’s income that meets the requirements above. Enter Code 300 and the
exempt income amount on the “Other Subtractions” line of your Oregon income tax return ....................................
Note: If you claim exempt Indian income, you can only file Oregon Form 40, 40N, or 40P. You can’t use Form 40S (short form).
ATTACH THIS FORM TO YOUR OREGON RETURN
150-101-687 (Rev. 07-10)
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