Form 90r - Oregon Elderly Rental Assistance Program - 2011 Page 5

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Child support included in
Funeral expenses received .................................. No
public assistance ............................................... Yes
Gains on sales (receipts less cost) .............. Yes
Clergy’s rental or housing allowance,
Excluded gain for Oregon on sale of home .... No
in excess of expenses claimed to
Gambling winnings (before losses) .......... Yes
determine federal AGI ................................. Yes
Gifts and grants (totaling more than $500) Yes
Compensation for services performed
Cash .............................................................. Yes
Back pay ....................................................... Yes
Gifts from spouse/RDP in the same
Bonuses ......................................................... Yes
household ........................................................... No
Clergy’s fees ................................................. Yes
Gifts other than cash (report at fair
Commissions ............................................... Yes
market value) .............................................. Yes
Director’s fees .............................................. Yes
Payment of indebtedness by another ...... Yes
Fees in general (trustee, executor,
Grants and payments by foreign
jury duty) ..................................................... Yes
governments (nontaxable) ........................... Yes
Lodging for convenience of employer ............. No
Meals for convenience of employer ................. No
Grants by federal government for
Salaries .......................................................... Yes
rehabilitation of home ......................................... No
Severance pay .............................................. Yes
Gratuities ........................................................ Yes
Tips ................................................................ Yes
Wages ............................................................ Yes
Hobby income ................................................ Yes
Deferred compensation
Honorariums .................................................. Yes
Contributions made ........................................... No
Individual Retirement Arrangement (IRA)
Payments received ...................................... Yes
Conventional IRA
Depletion in excess of basis ........................ Yes
Payments received ...................................... Yes
Payments contributed ........................................ No
Depreciation, depletion, and
Rollovers or conversions ................................... No
amortization in excess of $5,000 ................. Yes
Roth IRA
Disability income (entire amount) ............ Yes
Payments received ............................................. No
Payments contributed ................................. Yes
Dividends, taxable and nontaxable ........... Yes
Rollovers or conversions ................................... No
Credit union savings account
“dividends” (interest) ................................. Yes
Inheritance ..................................................... Yes
Insurance policy “dividends” (return
From spouse/RDP who resided with you ...... No
of premium) ....................................................... No
Insurance proceeds
Return of capital dividends .............................. No
Accident and health .................................... Yes
Stock dividends ........................................... Yes
Disability payments .................................... Yes
Tax-exempt dividends ................................ Yes
Employee death benefits ............................ Yes
Earned income credit, advanced........................ No
Life insurance .............................................. Yes
Estate and trust income (also see
Personal injury damages (less
Inheritance) (losses limited to $1,000)......... Yes
attorney fees) .............................................. Yes
Property damage if included in
Farm income (reduced by expenses)
federal income ............................................ Yes
(losses limited to $1,000) ................................ Yes
Reimbursement of medical expense ............... No
Agricultural program payments ............... Yes
Sick pay (employer sickness and
Patronage dividends ................................... Yes
injury pay) ................................................... Yes
Proceeds from sale of crops/livestock ..... Yes
Strike benefits .............................................. Yes
Rents ............................................................. Yes
Unemployment compensation .................. Yes
Sale of services ............................................. Yes
Workers’ compensation .............................. Yes
Fellowships..................................................... Yes
Interest, taxable and nontaxable ................ Yes
Foreign income (nontaxable) ....................... Yes
Contracts ...................................................... Yes
Municipal bonds and other securities...... Yes
Foster child care (reduced by expenses) .......... No
5
150-545-002 (Rev. 12-11)

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