Form 90r - Oregon Elderly Rental Assistance - 2004
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1
2Clear Form
OREGON
FORM
For department use only
2004
ELDERLY
Date received
90R
RENTAL
You must fill in your date of birth
ASSISTANCE
in order to receive assistance.
Last name
First name and initial
Enter your Social Security No. (SSN)
Date of birth
Remember
(mm/dd/yyyy)
–
–
to write in
Spouse’s last name if different
Spouse’s first name and initial
Enter spouse’s Social Security No.
Date of birth
your Social
(mm/dd/yyyy)
–
–
Security
Current mailing address
number
For department use only
1
2
3
and your
date
City
State
ZIP code
Telephone number
of birth
(
)
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 (total for 2004) ................................................... • 9
.00
10 Pensions and annuities (see instructions) ........................................ • 10
.00
11 Add lines 9 and 10 ............................................................................................................. 11
OTHER INCOME—Totals for the entire year
.00
12 Adult and Family Services (welfare) ................................................. • 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
19 Adjustments to income from federal Form 1040, line 35
.00
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 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
22 Total Oregon rent you paid during 2004 (from box 7 of rent schedule on the back)........................................ • 22
.00
23 Special Shelter Allowance (see page 15) ........................................................................................................ • 23
.00
24 Total fuel and utilities only (not telephone). Don’t include rent! (see page 15) ............................................. • 24
.00
25 Check the box if you paid rent to a:
nursing home
retirement/rest home or center
group home
Under penalties for false swearing, I declare that I have examined this claim, including ac com pa ny ing sched ules
I authorize the Department of
and statements. To the best of my knowledge and belief it is true, correct, and complete. If prepared by a person
Revenue to contact this preparer
other than the taxpayer, this dec la ra tion is based on all in for ma tion of which the preparer has any knowledge.
about the processing of this claim.
➨
SIGN
License No.
Your signature
Date
Signature of preparer other than taxpayer
HERE
➨
Address
Spouse’s signature (If filing jointly, BOTH must sign)
Mail your completed 90R to:
ERA CLAIMS, PO BOX 14700, SALEM OR 97309-0930
150-545-001 (Rev. 12-04) Web
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