Form 90R Fillable Oregon Elderly Rental Assistance (ERA)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

A nonprofit home for the elderly Amounts for food stamps or surplus foods Cooperative housing or dividends (interest) Yes Do not reduce these items by net operating loss I nc lu d e If you had a net loss it is limited to $1 000 In home services approved by the Oregon Limit the combined total of your depreciation Payments for medical care drugs medical Reimbursement of expenses from participating Special Shelter Allowance portion of TANF The total value of you and your spouse s/RDP s You and your spouse s/RDP s household income You didn t own your residence on December 31 You lived in Oregon on December 31; and You or your spouse/registered domestic partner You paid more than 20 percent of your household You rented an Oregon residence that was subject (checkbox) Unchecked (checkbox) Unchecked (Clear Form) Clear Form (if you live in a manufactured home see page 2) (losses limited to $1 000) Yes (RDP) were age 58 or older on December 31 2013; (SSDI) Yes (taxable and nontaxable) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 1 Real property (includes fair market value of mobile home) 1 Wages salaries and other pay for work 1 1 Your street address city state ZIP code 10 Pensions and annuities (see instructions) 10 10 Pensions and annuities Fill in the total pension 11 Add lines 9 and 10 11 12 Department of Human Services (DHS) benefits 12 DHS benefits (public assistance not including 13 Unemployment benefits 13 14 Veteran s and militar y benefits Fill in your 14 Veteran s and military benefits 14 15 Family support gifts and grants Add all the 15 Family support gifts and grants: Total received minus $500 15 150 545 002 (Rev 12 13) 150 545 002 (Rev 12 13) 1 150 545 002 (Rev 12 13) 2 150 545 002 (Rev 12 13) 4 150 545 002 (Rev 12 13) 5 150 545 002 (Rev 12 13) 6 16 O t her sou r ce s 16 Other sources: Identify 16 17 Add lines 12 through 16 17 18 Add lines 8 11 and 17 18 19 Adjustments to income from federal Form 1040 line 36 or federal Form 1040A line 20 19 2 Full name of each roommate 2 Interest and dividends (total taxable and nontaxable) 2 2 Personal property: 20 Your total household income Line 18 minus line 19 If your household income 2013 Elderly Rental Assistance Program 2013 for lights water garbage sewer and heating 2013 household assets list 2013 July 1 2014 July 1 2017 2014 so we can process and issue your payment in 21 Household assets 21 Your total household assets Fill in your total household assets from the 22 Total Oregon rent you paid during 2013 22 Total Oregon rent you paid during 2013 (from box 7 of rent schedule on the back) 22 23 percent of the payment is rent plus utilities 23 Special Shelter Allowance (see page 4) 23 23 Special Shelter Allowance (TANF) Did you 24 Fuel a nd ut ilit ies Include t he a mou nt you 24 Total fuel and utilities only (not telephone) Don t include rent (see page 1) 24 25 Check the box if you paid rent to a: nursing home retirement/care home or facility group home 25 Nursing home retirement/care home or facility 3 Business net income (loss limited to $1 000) 3 3 Landlord s name street address city state ZIP code and telephone 31 a nd you r spou s e/RDP l ived i n a home 31 there is no limit on the value of household 31 you may file separately List only the rent fuel 4 2013 rental period 4 Farm net income (loss limited to $1 000) 4 5 Rent you paid per month 5A 5B 5 Total gain on property sales (loss limited to $1 000) 5 58 or older as of December 31 2013 to qualify for 6 Rental net income (loss limited to $1 000) 6 6 Total rent you paid (per address) 6A 6B 60 percent of your total payment is considered rent 7 Other income from your federal return Identify 7 7 Total rent paid in 2013 Add boxes 6A and 6B and enter the total here 8 Add lines 1 through 7 8 9 Social Security supplemental security income (SSI) 90R If the total value of both your household 90R If the total value of your household assets 90R is filed after July 1 your check can t be issued 90R Your spouse/RDP will file a separate Form 90R a deceased person A Money on hand: Currency checks or others (identify) a payment in lieu of tax (PILOT) You must Accident and health Yes Act on RDPs in Oregon For updated information actually paid on the Form 90R rent schedule Don t Address Address advance rent or deposits for keys cleaning or agreement along with your rent receipts for your agreement and the relative you pay rent to must Agricultural program payments Yes Aid to blind and disabled Yes Alimony and separate maintenance Yes allowance in excess of expenses allowances Also enter this amount in box 22 on the front of this form 7 Also include Temporary Assistance for Needy Americans with Disabilities Act (ADA): Call one of amortization in excess of $5 000 Yes amount for you Remember your assistance payment amount of assistance is based on the rent fuel utilities amount you received Don t include: amount you received plus interest and 10 percent is considered fuel and utilities and annuity income you received in 2013 and fuel (see Special living places on page 2) and nontaxable income for the entire year Include and nontaxable interest and dividends Don t and utilities you paid File jointly if you are only and you rented the land you may file a claim based and your spouse s/RDP s date of birth? and your spouse/RDP on Form 90R or your claim Annuities and pensions (reduced by apart on December 31 It also doesn t i nclude Apartment managers Include only the rent you apply Fill in 0 on line 21 ) If your household assets exceed $25 000 STOP HERE Asistencia en espa ol: assets combined is more than $25 000 you don t assets); and Assistance Summary statement that shows the assistance Yes attorney fees) Yes B Money on deposit: back of this form (If you or your spouse/RDP are age 65 or older the limitations do not Back pay Yes be fined up to $100 000 and serve a jail sentence before November 2014 notify us See page 4 Before you mail Form 90R check for the following: Board benefits you received in 2013 Include board payment is considered rent and 10 percent board see Special living places on page 2 Boarders Generally 60 percent of your room and Bonuses Yes Business income (reduced by C Funds on deposit: cable tv or internet access Cafeteria plan benefits No Capital common and preferred Capital loss carryover No Capital losses (in year determined) care but retirement/care homes or centers and carryovers and carrybacks Cash Yes Certificates of deposit or others (identify) Checking and savings account checklist checklist on page 4 Child care payments Yes Child support included in Child support included in public Child support Yes Foster child care (reduced by expenses) No Children s benefits paid to parent Yes Children s benefits paid to your child No CityStateZIP codeTelephone number CityStateZIP codeTelephone number claim based on the rent you actually paid for your claim could delay your assistance until next year Claim Year File By Accepted Until Clearly print or type your name address Social Clergy Members of the clergy who live in housing Clergy s fees Yes Clergy s rental or housing allowance Combat pay Yes Commissions Yes Compensation for services performed complete list ) Contracts Yes Contributions made No Conventional IRA corporations cost recovery) Yes could be charged with a class C felony You could Court s decision regarding the Defense of Marriage Credit union savings account Current mailing address Current mailing address D Money owed to you: Personal or business notes receivable or others (identify) Date of birth (mm/dd/yyyy) Date of birth (mm/dd/yyyy) Date of birth (mm/dd/yyyy) Date of birth (mm/dd/yyyy) Date of birth You or your spouse/RDP must be age Date received Date received Deceased persons You cannot file a Form 90R for December 31? Did you fill in your date of birth deductions Do not include reimbursed medical Deferred compensation Department of Human Services Department of Human Services No depletion and amortization deductions to $5 000 Depletion in excess of basis Yes Depreciation depletion and described on page 4 See the list on Form 90R determine federal AGI Yes determining AGI) (limited to $1 000) Yes Did you and your spouse/RDP sign and date Did you complete the entire form? An incomplete Direct payments to nursing home No Director s fees Yes Disabilit y income (entire amount) Yes Disability payments Yes Disability pension Yes Disability pensions Yes Dividends taxable and nontaxable Yes Do not include food expenses or payments for telephone Do not list any amounts paid by anyone else dollar For example $12 49 becomes $12 Don t include amounts for telephone cable or Don t include payments to your nursing home E Value of shares of stock: each of you can file a separate Form 90R for assistance Earned income credit advanced No Earned income credit No Educational benefits (GI Bill) Yes Elderly Rental Assistance (ERA) is for low income eligible for ERA unless the property owner makes Employee death benefits Yes En Salem o fuera de Oregon 503 378 4988 Enter spouse s/RDP s Social Security no Enter spouse s/RDP s Social Security no Enter your Social Security no (SSN) Enter your Social Security no (SSN) ER A payment We will figure your assistance ERA CLAIMS ERA You must enter the date of birth for yourself Estate and trust income (also see Excluded gain for Oregon on sale of home No exempt from property taxes you are allowed exempt from property taxes you are not eligible exempt from property taxes you can t file for ERA expenses Include any amounts you received in expenses) (losses limited to $1 000) Yes expenses) (losses limited to $1 000) Yes f rom Sen iors and People with Disabil it ies F Value of assets or property used in a trade or business in which you or your spouse/RDP Families (TANF) You should have received an Family allowances Yes Farm income (reduced by expenses) federal grants to improve your home federal income Yes Federal pensions: Be sure to include your total Federal tax No Fees in general (trustee executor Fellowships Yes file a Form 90R to receive ERA file for ERA unless the owners make a PILOT Filing a fraudulent Form 90R is against the law You Fill in the total amount of public assistance Fill in the total amount received during the year Fill in the total taxable and nontaxable Social First name and initial First name and initial Food stamps (or cash payments in lieu food stamps) 12 For department use only For department use only For each of the following fill in the total amount for guidance on the impact of the U S Supreme for medical care drugs or medical supplies for numbers to call for the right to occupy the property you may for which you received no direct payment Foreign income (nontaxable) Yes Form 90R and Instructions Form 90R instructions Form 90R page 2 of 2 150 545 002 (Rev 12 13) Form 90R? Form90ROregon Elderly Form90ROregon Elderly formats Fraudulent claims from property taxes or you lived in a nursing From sales of real or personal From spouse/RDP who resided with you No From: To: From: To: fuel and utilities Fuel and utilities include the amount you paid in fuel and utilities Note: If your group home is Fuel assistance No fuel utilities household income and assets of both Funds accruing due to death of the insured where withdrawal is at your option (insurance) Funds accruing due to original maturity of a policy contract where withdrawal is at your option Funeral expenses received No gain from any property sales: stocks bonds gain you deferred or excluded from the sale of Gains on sales (receipts less cost) Yes Gambling winnings (before losses) Yes General tax information www oregon gov/dor Generally a nursing home provides medical GI Bill benefits family allowances and educational Gifts and grants (totaling more than $500)Yes Gifts from spouse/RDP in the same gifts grants and scholarships you received Gifts other than cash (report at fair governments (nontaxable) Yes Grants and payments by foreign Grants by federal government for Gratis de prefijo de Oregon 1 800 356 4222 Gratuities Yes group homes don t Group homes Generally 60 percent of your total have an ownership interest Have questions? Need help? Hobby income Yes home or center group home or paid room and home or pay room and board only a portion is home retirement/rest home or center group home you may file for ERA Nursing home payments Honorariums Yes Household assets include real and personal property household assets is $25 000 or less (if you or your household assets list on the back of your Form Household income household income and assets of each person Household income checklist Household income includes all taxable and nontaxable Household income includes taxable and nontaxable household No housing is exempt from property taxes you can t housing you lived in Note: If your residence is I m p or t a n t I f y o u r a d d r e s s c h a ng e s i nc om e f r om p a r t ne r s h i p s a n d S I nco me (S SI ) S o c ia l Se c u r it y D i s abi l it y i ncome See pages 4 6 for a household i ncome if the property you rent is 75 percent exempt from If the property you rented was partially exempt If the total of lines 22 and 24 is 20 percent or less If you file Form 90R by July 1 2014 your ERA check If you lived in a nursing home on Decem ber If you lived in a nursing home on December 31 If you lived in a nursing home retirement/rest If you receive public assistance benefits for your in 2013 in excess of expenses claimed to In home services approved by the in household income even if it is not taxable in Oregon under Taxpayer Tips in total household income in work or training programs in your household Yes Include all Oregon rent you paid for each residence Include any amounts you received from others include medical care and other expenses include return of capital dividends or insurance include the value of free rent include your contribution to the plan Include income for rent fuel and utilities (see Special income from sources inside and outside Oregon income of any other person living with you except income of both spouses/RDPs living in the income See page 2 incurred by participants in work Individual Retirement Arrangement (IRA) Inheritance Yes Inheritance) (losses limited to $1 000) Yes injury pay) Yes Instructions are for lines not fully explained on instructions on this page); and Insurance (SSDI) and railroad retirement Insurance policy dividends (return Insurance proceeds Interest and dividends Fill in your total taxable Interest taxable and nontaxable Yes internet is $10 000 or more STOP HERE You don t qualify for elderly rental assistance 20 is based on your income assets and the amount of is considered fuel and utilities is considered rent and 3 percent is considered is more than $25 000 you don t qualify for ERA is subject to Oregon property taxes For example jury duty) Yes land or other property If you had a net loss Last name Last name Licensed trailers If you lived in a licensed travel Life insurance Yes Line instructions List the names of all renters and the rent fuel and List the places you rented in Oregon during 2013 Attach additional schedules if needed Lodging for convenience of employer No Losses on sales (to extent used in Lottery winnings Yes Low income housing You can file for ERA only on Lump sum distribution (less cost lump sum distributions and death benefits manufactured home your land or both If you Manufactured homes You are allowed to file a market value) Yes Married/RDP living apart If you were married/ Married/RDP living together Complete the Married/RDP living together If you were married/ may be denied Meals for convenience of employer No Medical payments to doctors No medical supplies and services for Medicare payments of medical expenses No Medicare premiums deducted from Military and veteran s benefits Municipal bonds and other securities Yes must file jointly The assistance is based on the rent Name and address section Net operating loss carryback and carryover No Nonresidents and part year residents who lived in nontaxable) (reduced by cost not included in federal AGI Yes not just rent Generally 20 percent of your total payment Note for lines 3 4 and 6: Note: Examples of items not to include are: TVs Note: You must rou nd off cents to the nearest notice on this line This allowance is an advance November 2014 nursing home costs include 23 percent of that nursing home rent if it is subject to property tax Nursing home residents If you lived in a nursing nursing home retirement/care home or facility group home o n you r nu r s i n g h o m e r e nt S h ow o n ly yo u r o w n h o u s e h o l d i n c o m e o n F o r m 9 0 R Yo u r of a minor child of food stamps) No of premium) No of your TANF Fill i n the amou nt from t he of your total household income on line 20 then Old age benefits Yes on the impact of that decision and how to file as on the land rent you paid only the rent fuel and utilities you actually paid or group home Check the box that applies or training programs No order to receive assistance order to receive assistance Oregon income tax No Oregon on December 31 2013 Include all taxable Oregon Supplemental Income Other income Other income Totals for the entire year Other states income tax (if in federal AGI) Yes owned both on December 31 you don t qualify for page 2 paid duri ng 2013 for l ights water garbage Parsonage (rental value) or housing Partially exempt property If your residence is partially Partnership income (reduced by Patronage dividends Yes payment as public assistance income Generally payment is considered rent and 10 percent is considered payment of ERA and will reduce the amount of Payment of indebtedness by another Yes Payments contributed No Payments contributed Yes Payments for medical care drugs Payments received No Payments received Yes Pensions and annuities (taxable and Pensions Yes people people age 58 or older who rent their home ERA percent of the rent you actually paid personal and select Registered domestic partners Personal injury damages (less PILOT Contact your landlord if you don t know if PO Box 14700 policy return of premium dividends Prior year rental assistance payment No Prizes and awards Yes Proceeds from sale of crops/livestock Yes Program (OSIP) Yes program (WIC) No property (nonbusiness) No Property damage if included in Property tax No property taxes you may file a claim based on 25 provided by the church may be eligible for assistance Public assistance benefits Yes public assistance Yes qualify for ERA Include property you own qualify for ERA You must have a signed rental Qualifying rent Qualifying rent qualifying rent See Special living places on railroad retirement (taxable and nontaxable) 9 Railroad Retirement Board benefits Yes RDP and living together on December 31 you RDP and permanently living apart on December RDP s i ncome i f you were perma nently l ivi ng RDP/Defense of Marriage Act (DOMA) At the RDPs visit our website at www oregon gov/dor/ Re t i r e ment /c a r e home or fac i l it y G e n e r a l ly receive TANF? If you did the Assistance Summary Recently married/registered Did you marry or records recover y) Yes recovered in the current year) Yes Refunds register your domestic partnership during 2013? If rehabilitation of home No Reimbursement of medical expense No Reimbursements (in excess of expenses) Yes Reimbursements of expenses paid or Remember You must file Form 90R by July 1 rent fuel and utilities you paid The property you rent must be subject to property tax If the property Rent schedule Rental allowances paid to ministers Rental and royalty income (reduced by Rental Assistance2013For department use only Rental Assistance2013For department use only Renting from relatives If you pay rent to a relative Rents Yes report the rental income Keep a copy of the signed Residence A Residence B (if needed) Residence sales (see gains on sales) Yes Retirement benefits (see pensions and Retirement income Retirement income Totals for the entire year Return of capital dividends No rings and bicycles (This is not intended to be a Rollovers or conversions not included in AGI No Roommates Each roommate can file for ERA The Roth IR A S o c i a l Se c u r it y Su p ple me n t a l Se c u r it y Salaries Yes Sale of services Yes Salem 503 378 4988 Salem area or outside Oregon 503 945 8617 Salem OR 97309 0930 same household It doesn t include your spouse s/ Savings accounts Yes Scholarships (totaling more than $500) Yes security Keep your rent receipts for at least Security number and date of birth on Form 90R Security SSI SSDI and Railroad Retirement See t he hou sehold i ncome Severance pay Yes sewer and heat i ng wh ile livi ng i n Oregon Shares in mutual funds and investment trusts or others (identify) Show only your own household income on Form Sick pay (employer sickness and Sick pay Yes Sign and mail Form 90R Signature of preparer other than taxpayerLicense no Signature of preparer other than taxpayerLicense no Single If you were single on December 31 2013 list Single or married living apart Complete the so you must file jointly Include the rent fuel and Social Security (taxable and nontaxable) Yes Social Security before any Medicare premium Social Security Disability Insurance Social Security Yes Social Security) Yes Special instructions Special living places Special Shelter Allowance No Spouse s/RDP s first name and initial Spouse s/RDP s first name and initial Spouse s/RDP s last name if joint claim Spouse s/RDP s last name if joint claim Spouse s/RDP s signature (If filing jointly BOTH must sign) Spouse s/RDP s signature (If filing jointly BOTH must sign) spouse/RDP are age 65 or older on December spouse/RDP doesn t qualify for ERA statement you received shows the amount Stipends (totaling more than $500) Yes Stock dividends Yes Strike benefits Yes Supplemental Security Income (SSI) Yes supplies and services related to medical care Support from parents who don t live Surplus food No Survivor benefits Yes Tax exempt dividends Yes Tax exempt interest Yes taxable and nontaxable pension income Don t temporarily living apart Temporary assistance to needy families Yes The amount of assistance depends on the kind of the form the help numbers above for information in alternative the rent you actually paid Note: If your low income three years time this publication was printed we were waiting Tips Yes to $500 from household income Don t include to file an ERA claim based on the percentage that to file for ERA unless the property owners make a to help pay your expenses You can exclude up to property tax or PILOT; and together and separately Toll free from an Oregon prefix 1 800 356 4222 Toll free from an Oregon prefix 1 800 886 7204 Total gain on property sales Fill in your total Total household assets Fill in the total here and on line 21 on the front of this form total taxable and nontaxable veteran s benefits trailer that s not on the county property tax rolls Trust income Yes TTY (hearing or speech impaired; machine only): U S Savings Bonds Yes Unemployment compensation Yes until November 2015 Use fair market value of your assets as of December 31 2013 If you or your spouse/RDP are age 65 or older this list is not required Use Form 90R lines 1 19 to figure your household Use this list to decide if an item must be included used in determining federal AGI Yes utilities paid both separately and together utilities you alone paid VCRs computers cars furniture appliances Wages Yes was subject to Oregon property tax was under $10 000; and Were you or your spouse/RDP age 58 or older on When do I file Form 90R? When will I get my assistance check? Where do I send Form 90R? which no direct payment is received No while your spouse/RDP rented a separate residence will be mailed to you in November If your Form will be reduced by any TANF you received Women Infants and Children Work and investment income Work and investment income Totals for the entire year Workers compensation Yes you can subtract up to $1 000 Don t include any you don t qualify You don t qualify for elderly rental assistance 21 You don t qualify for ERA if you lived in: You may file for assistance based on your You must fill in your date of birth in You must fill in your date of birth in you ow ne d you may f i le for a ssi st a nce based You qualify for ERA if all the following are true: You qualify if you paid rent and the property you received during the year you received Include amounts received you rent is exempt from property tax you are not you rented in 2013 Rent doesn t include You would also be required to pay back twice the your assistance your house Your minister s rental allowance must be included your name from Social Security for the benefit your residence is subject to property tax or PILOT Your signatureDate Your signatureDate your spouse/RDP