101 178
Attach this schedule to your Oregon return
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(Clear Form) Clear Form
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1 800 356 4222)
1 Maximum credit amount 1
2 Enter the amount that was paid to you because the park closed due to eminent domain 2
3 Line 1 minus line 2 3
4 Enter the total credit amount claimed by all other owners of your mobile home 4
5 000 00
5 Your credit: Line 3 minus line 4 Enter this amount on Form 40S 40 40N or 40P 5
503 378 4988
address
Address of your mobile home at closing park (include city state and ZIP code)
agreement
along
because
closing
closing
closing
closure
contact
Date the park owner or landlord gave you the park closure notice (mm/dd/yyyy)
Date you and all members of your household moved out of mobile home park (mm/dd/yyyy)
Dates you occupied your mobile home as principal residence at the closing park
filing
first
First name and initial
For tax year
From To
home;
home;
household
Important documents to keep with your tax records to support your claim:
Important: If you claim this credit you must keep the important documents listed below with your tax records for three
Important: This credit must be claimed for the year you moved out of the mobile home park For more information visit
initial
Last name
Lease
List the name(s) and Social Security number(s) of all owners of your mobile home:
listing
lived
Manager s name and phone number
manufactured
married
members
Members of your household include you your spouse or registered domestic partner (unless you lived apart the entire
mm dd y yyy mm dd y yyy
mobile
mobile
mobile
mobile
Mobile Home Park Closure
moved
Name of closing park
Name of other owner(s) SSN of other owner(s) Did they live with you at any time during the year?
notice
notice
number
occupant
occupied
Oregon
owned
ownership
prefix
principal
Proof
received
registered
Rented
residence;
returns)
Schedule
Security
separate
showing
Social
Social Security number (SSN)
space
Spouse s/RDP s
Spouse s/RDP s
telling
To qualify you must have:
toll free
where
while
written
www oregon gov/DOR
year) and anyone else who lived in your home with you during any part of the year
years after the year the credit has been claimed Do not send these items unless requested
Yes No
Yes No
You may qualify for this credit if you moved out of a mobile (or manufactured) home park because it closed or was closing