Form 150-310-103 - Statement Of Rental Income By A Farm Labor Camp And/or Day Care Center

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STATEMENT OF RENTAL INCOME
BY A FARM LABOR CAMP AND/OR DAY CARE CENTER
Pursuant to ORS 307.490
• This statement must be filed on or before November 15, ________. Filed with the _________________________ County Treasurer.
Code and Account Number
THIS SPACE FOR COUNTY TREASURER’S USE ONLY
Name of Organization
Date Received
Amount Received
$
Street Address
X
Received by:
City
City
State
ZIP Code
Title:
Telephone Number
In accordance with ORS 307.490, the amount of rental income received by:
operated as a:
Farm Labor Camp
Day Care Center
Name of Organization
for the 12-month period ending October 15, _________, was as follows:
1. INCOME RECEIVED
2. LESS EXPENSES
A. Day care center ........................... ________________________
A. Utilities ........................................ _______________________
B. Labor camp rental ....................... ________________________
B. Garbage disposal ........................ _______________________
C, User fees ..................................... ________________________
C. Repairs and maintenance ........... _______________________
D. Interest ........................................ ________________________
D. Depreciation ................................ _______________________
E. Other (describe):
________________________
E. Insurance .................................... _______________________
_______________________
________________________
F. Property taxes ............................. _______________________
_______________________
________________________
G. Salaries ....................................... _______________________
_______________________
________________________
H. Supplies ...................................... _______________________
_______________________
________________________
I.
Interest and capital cost ............. _______________________
F. Total Income ................................ ________________________
J. Total Expenses .......................... _______________________
3. Net income (line 1F minus line 2J
..................................................................................................................... _______________________
4. Payment in lieu of taxes (10 percent of net income shown on line 3) .................................................................. _______________________
I affirm that:
• The facilities have complied with the requirements of the state Fire Marshal.
• The day care center complies with the requirements of the Children’s Services Division, Department of Human Resources.
• The facility complies with the health code for farm labor camps adopted under the Oregon State Employment Act.
I declare under the penalties for false swearing as contained in ORS 305.990(4) that this statement has been examined by me and to
the best of my knowledge it is true, correct, and complete.
X
Signature of officer making statement
Date
Title
150-310-103 (Rev. 2-00)
Distribution: White—County Treasurer
Canary—Oregon Department of Revenue
Pink—County Assessor
Goldenrod—Applicant
See other side for instructions and applicable law

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