Form WFC-DP Fillable Verification of Disabled Parent or Guardian for Oregon Working Family Child Care Credit
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

revoked YOU MUST ATTACH THIS FOrM TO YOUr OrEGON INCOME TAX rETUrN (Clear Form) Clear Form 150 101 177 (Rev 12 08) across after Attach this form to your tax return If you file your return electronically fax this completed form to: 503 945 8786 Attn: Suspense; Attending authorization Being by the Oregon Department of Revenue care; Check the activities of daily living that your patient required assistance with: child Department of Revenue Did your patient meet the criteria listed above for the entire tax year indicated at the top of this form? disability disclose Do you expect your patient to continue to meet the criteria listed above for the foreseeable Dressing Feeding Toileting Other activity of daily living: during employed; enter Permanent instead of the tax year Your physician will need to complete Section B and keep a copy of this form signed by you For tax year for the working family child care credit future because the disability is permanent? gainfully has completed this form verifying that you have a permanent qualifying disability keep the original form and attach a copy of it to your I give permission for the physician and the physician s employees to verify the existence and severity of my disability and other information I verify that the above person was unable to care for him or herself and had a disability that required assistance with one or more activities If not enter the dates during the year that your patient met the above criteria: to Important: Important: The law was changed in 2007 to allow an exception if a spouse or registered domestic partner is disabled as described in ORS 315 262 This exception is not available for tax year 2006 or earlier This form is for tax years 2007 or later Instructions: Enter the name and Social Security number of the disabled taxpayer above If the disability is not permanent enter the Last name of disabled taxpayer First name of disabled taxpayer Social Security no (SSN) of disabled taxpayer least not permanent you will need to obtain a new verification form for each tax year you have a qualifying disability Note to physician: The Department of Revenue may contact you to verify this information of daily living during the tax year indicated at the top of this form This disability kept the person from doing all of the following: on this form with the Oregon Department of Revenue This authorization for this tax year expires four years from the date received or mail it to: COR TROL Attn: Suspense PO Box 14999 Salem OR 97309 0990 Oregon Oregon Form Verification of Disabled Parent or Guardian permanent you are not required to fill out a new Form WFC DP each year that you claim this credit When your physician physician Physician s last name Physician s first name Physician s office address Physician s office phone Physician s signature Please print or type: Providing records return return each year that you claim the working family child care credit Write Permanent in the tax year box at the top of this form revoke school Section A To be completed by patient Section B To be completed by physician Signature of disabled taxpayer so that we may verify the information provided tax year If the disability is permanent and the physician identifies that the taxpayer will permanently meet the criteria listed below that time WFC DP for Oregon Working Family Child Care Credit write years