Form 90R – Fill Out and Use This PDF

Elderly Rental Assistance (ERA) is for low-income people age 58 or older who rent their home. ERA is based on your income, assets, and the amount of rent, fuel, and utilities you paid. he property you rent must be subect to property ta. f the proper ty you rent is eempt from property tayou are not eligible for ERA unless the property owner maes

a “payment in lieu of ta” (). ou must file a orm R to receie ERA.

You qualify for ERA if ALL the following are true:

•ou or your spouseregistered domestic partner

(R)were age 58 or older on ecember,

and

• ou and your spouse’sR’s household income

was under ,

and

•ou paid more than percent of your household income for rent, fuel, and utilities (see “pecial instructions” on this page) and

•he total alue of you and your spouse’sR’s household assets is 5, or less (if you or your spouseR are age 5 or older on ecember ,

there is no limit on the alue of household assets) and

•ou rented an regon residence that was subect

to property tar	and
• ou lied in regon on ecember		and

•ou didn’t own your residence on ecember

(if you lie in a manufactured home, see page ).

Household income includes all taable and nonta- able income. ee page .

Fuel and utilities include the amount you paid in for lights, water, garbage, sewer, and heating.

o not include food epenses or payments for tele- phone, cable t, or internet access.

Household assets include real and personal prop- erty described on page . ee the list on orm R.

When do I file Form 90R?

Claim Year	File By	Accepted Until
2010	July 1011	July 101

Where do I send Form 90R?

ERA A o00

alem R 000

When will I get my assistance check?

f you file orm R by uly ,, your ERA chec

will be mailed to you in oember. f your orm R is filed after uly , your checcan’t be issued until oember .

Fraudulent claims

iling a fraudulent orm R is against the law. o	u
could be charged with a class felony. ou could
be fined up to , and sere a ail sentence.
ou would also be reuired to pay bactwice the
amount you receied plus interest.

Special instructions

ingle f you were single on ecember,, list

only the rent, fuel, and utilities you actually paid. o not list any amounts paid by anyone else.

Roommates Each roommate can file for ERA. he amount of assistance is based on the rent, fuel, utili- ties, household income, and assets of each person. st the names of all renters and the rent, fuel, and utilities you alone paid.

Recently marriedregistered id you marry or register your domestic partnership during f

so, you must file ointly. nclude the rent, fuel, and utilities paid both separately and together.

arriedR—liing together f you were mar-

riedR and liing together on ecember,,

you must file ointly. he assistance is based on t he rent, fuel, utilities, household income, and assets of both people.

rriedR—liing aart you were married

R and permanently liing apart on ecember

,you may file separately. st only the rent, fuel, and utilities you paid. ile ointly if you are only temporarily liing apart.

eceased sons ou cannot file a orm R for a deceased person.

lergy embers of the clergy who lie in housing proided by the church may be eligible for assis- tance.ou ualify if you paid rent and the roerty was suect to regon roty ta

our minister’s rental allowance must be included in household income een if it is not taable.

Aartment managers nclude only the rent you actually paid on the orm R rent schedule. on’t include the alue of free rent.

Special living places

he amount of assistance depends on the ind of housing you lied in. ote: f your residence is eemt from roty taesyou are not eligile

to file for ERA unless the property owners mae a

.ontact your landlord if you don’t now if your residence is subect to property tar .

artially eem roerty f your residence is par- tially eempt from property taes, you are allowed to file an ERA claim based on the percentage that is subct to regon property taes. or eample,

if the property you rent is 5 percent eempt from property taes, you may file a claim based on 5 percent of the rent you actually paid.

anufactured homes ou are allowed to file a claim based on the rent you actually paid for your manufactured home, your land, or both. f you owned both on ecember , you don’t ualify for ERA.

owincome housing ou can file for ERA only on the rent you actually paid. ote: f your low-income housing is eempt from property taes, you can’t file for ERA unless the owners mae a .

ursing home residents f you lied in a nursing home, you may file for ERA. ursing home pay- ments include medical care and other epenses, not ust rent. enerally, percent of your total p ay- ment is considered rent, and percent is considere d fuel and utilities.

f you lied in a nursing home on ecember,	,
while your spouseR rented a separate residence,
each of you can file a separate orm R for assis-
tance. ou may file for assistance based on your
nursing home rent if it is subect to property ta.
how only your own household income on orm
R.our spouseR will file a separate orm R.

f you li ed in a nursing home on ecem- ber , and your spouseR lied in a home

you owned, you may file for assistance based on your nursing home rent. how only your own household income on orm R. our spouseRoesn’t ualify for ERA.

Retirementcare home or facility enerally, percent of your total payment is considered rent , and ercent is considered fuel and utilities.

rou homes enerally, percent of your total payment is considered rent, and percent is consi d- ered fuel and utilities. ote: f your group home is eempt from property taes, you can’t file for ERA.

oarders enerally, percent of your room and board payment is considered rent, and percent is considered fuel and utilities.

Renting from relaties f you pay rent to a rela- tie for the right to occupy the property, you may ualify for ERA. ou must hae a signed rental agreement and the relatie you pay rent to must report the rental income. eep a copy of the signed agreement along with your rent receipts for your records.

icensed trailers f you lied in a licensed trael trailer that’s not on the county property tarolls, and you rented the land, you may file a claim based on the land rent you paid.

You don’t qualify for ERA if you lied in:

•	ooperatie housing or
•	A nonprofit home for the elderly.

Form 90R instructions

Name and address section

learly print or type your name, address, ocial ecurity number, and date of birth on orm R.

Important—f your address changes

efore oemer 2011 notify us ee page for numbers to call.

ate of irth ou or your spouseR must be age 58 or older as of ecember , , to ualify for

ERA. You must enter the date of irth for yourself and your souseR on Form 0R or your claim may e denied

Household income

ousehold income includes taable and nonta- able income of both spousesRs liing in the same household. t doesn’t include your spouse’s R’s income if you were permanently liing apart on ecember . t also doesn’t include income of any other person liing with you, ecept your spouseR.

se orm R lines –to figure your household income. ee pages - for a household income checlist.

onresidents and artyear residents who lied in

regon on ecemer 12010	nclude all taable
and nontaable income for the	entire year. nclude

income from sources inside and outside regon.

Line instructions

nstructions are for lines not fully eplained on the form.

ote: ou must round off cents to the nearest dollar. or eample, .comes .

Work and investment income

ill in the total amount receied during the year.

2nterest and diidends ill in your total taable and nontaable interest and diidends. on’t include “return of capital” diidends or insur- ance policy “return of premium” diidends.

ote for lines nd :

•f you had a net loss, it is limited to ,.

•nclude income from partnerships and corporations.

•o not reduce these items by net operating loss carryoers and carrybacs.

•imit the combined total of your depreciation, depletion, and amortiation deductions to 5,.

otal gain on roty sales ill in your total

gain from any property sales stocs, bonds, land, or other property. f you had a net loss, you can subtract up to,. on’t include any gain you deferred or ecluded from the sale of your house.

Retirement income

or each of the following, fill in the total amount you receied during the year.

ocial ecurity u lemental ecurity ncome ocial ecurity isaility nsurance and railroad retirement

ill in the total taable and nontaable ocial ecurity, , , and Railroad Retirement oard benefits you receied in . nclude ocial ecurity efore any edicare premium deductions. o not include reimbursed medical epenses. nclude any amounts you receied in your name from ocial ecurity for the benefit of a minor child.

10ensions and annuities ill in the total pen-

sion and annuity income you receied in. Federal ensions: e sure to include your total taable and nontaable pension income. on’t include your contribution to the plan. nclude lump-sum distributions and death benefits.

Other income

12hildren Adults and Families AF ill

in the total amount of public assistance you receied. nclude amounts receied from eniors and eople with isabilities. Also include emporary Assistance for eedy amilies (A). ou should hae receied an Assistance ummary statement that shows the amount you receied. n’t include:

•pecial helter Allowance portion of A.

•Amounts for food stamps or surplus foods.

•ayments for medical care, drugs, medical supplies, and serices related to medical care for which you receied no direct payment.

•n-home serices approed by the regon epartment of uman erices.

•Reimbursement of epenses from participat- ing in worr training programs.

f you receie public assistance benefits for your nursing home costs, include percent of that payment as public assistance income. enerally, percent of the payment is rent plus utilities and fuel (see “pecial liing places” on page ). on’t include payments to your nursing home for medical care, drugs, or medical supplies.

1eteran’s and military enefits ill in your

total taable and nontaable eteran’s benefits, ill benefits, family allowances, and educa- tional allowances.

1Family suortgiftsand grants Add all the

gifts, grants, and scholarships you receied. nclude any amounts you receied from others to help pay your epenses. ou can eclude up to from household income. on’t include federal grants to improe your home.

1ther sources	ee the household income
checlist on page .
21Household assets
ingle or married—liing aart		omplete the

household assets list on the bacof your orm R. f the total alue of your household assets is more than 5, you don’t ualify for ERA.

arriedR—liing together omplete the

household assets list on the bacof your orm R. f the total alue of both your household assets combined is more than 5,, you don’t ualify for ERA. nclude property you own together and separately.

ote: Eamples of items not to include ares, Rs, computers, cars, furniture, appliances, rings, and bicycles. (his is not intended to be a complete list.)

Qualifying rent

22otal regon rent you aid during 2010

nclude all regon rent you paid for each resi- dence you rented in . Rent doesn’t include adance rent or deposits for eys, cleaning, or security. eep your rent receipts for at least three years.

the property you rented was partially eempt from property taes, or you lied in a nursing home, retirementrest home or center, group home, or pay room and board, only a portion is ualifying rent. ee “pecial liing places” on page .

2ecial helter Allowance AFid you

receie Af you did, the Assistance um-

mary statement you receied shows the amount of your A. ill in the amount from the notice on this line. his allowance is an adance payment of ERA and will reduce the amount of your assistance.

2Fuel and utilities nclude the amount you paid during for lights, water, garbage, sewer, and heating while liing in regon. n’t include amounts for telephone, cable, or internet.

f the total of lines and is percent or l ess of your total household income on line , then you don’t ualify.

f you lied in a nursing home, retirementrest home or center, group home, or paid room and board, see “pecial liing places” on page .

2ursing homeretirementcare home or facil ityor grouhome hecthe bothat applies. enerally, a nursing home proides medical care, but retirementcare homes or centers and group homes don’t.

ERA ayment he regon epartment of Reenue will figure your assistance amount for

you. Remember your assistance payment will be reduced by any Aou receied in .

Sign and mail Form 90R

efore you mail orm R, checfor the following

✓ere you or your spouseR age 58 or older on ecember id you fill in your date of birth and your spouse’sR’s date of birth

✓id you and your spouseR sign and date orm R

✓id you complete the entire form An incomplete claim could delay your assistance until net year.

Remember—ou must file orm R by uly , so we can process and issue your payment in oember.

Have questions? Need help?

General tax information	www.oregon.godor
lem		5-8-88
oll-free from an regon prefi		...-8-5-
Asistencia en español:
En lem o fuera de regon		5-8-88
ratis de prefio de regon		-8-5-

TTY (hearing or speech impaired; machine only):

lem area or outside regon	5-5-8
oll-free from an regon prefi	... -8-88-

Americans with Disabilities Act (ADA): all one of the help numbers aboe for information in alterna- tie formats.

Household income checklist

se this list to decide if an item must be included in total household income.

Alimony and searate maintenance		.......... es
Annuities and nsions reduced y
cost recoery		es
usiness income reduced y
enses	(losses limited to ,)	es
afeteria lan enefits		o
aital loss carryoer		o
aital losses in year determined
(losses limited to ,)		es
hild suort	.................................................	es

hild suort included in
ulic assistance	es
lergy’s rental or housing allowance
in ecess of enses claimed to
determine federal A	es
omnsation for serices formed
acay	es
onuses	es
lergy’s fees	es
ommissions	es
irector’s fees	es
ees in general (trustee, eecutor,
ury duty)	es
odging for conenience of employer	o
eals for conenience of employer	o
laries	es
eerance pay	es
ips	es
ages	es
eferred comnsation
ontributions made	o
ayments receied	es
eletion in ecess of asis	es
ereciationeletionnd
amortiation in ecess of 000	es
isaility income entire amount	es
iidendsaale and nontaale	es
redit union saings account
“diidends” (interest)	es
nsurance policy “diidends” (return
of premium)	o
Return of capital diidends	o
tociidends	es
a-eempt diidends	es
Earned income creditdanced	o
Estate and trust income also see
nheritance (losses limited to ,)	es
Farm income reduced y enses
(losses limited to ,)	es
Agricultural program payments	es
atronage diidends	es
roceeds from sale of cropsliestoc	es
Rents	es
le of serices	es
Fellowshis	es
Foreign income nontaale	es
Foster child care reduced y enses	.......... o

Funeral enses receied	o
ains on sales receits less cost	es
Ecluded gain for regon on sale of home .... o
amling winnings efore losses	es
ifts and grants totaling more than 00	es
ash	es
ifts from spouseRn the same
household	o
ifts other than cash (report at fair
maret alue)	es
ayment of indebtedness by another	es
rants and ayments y foreign
goernments nontaale	es
rants y federal goernment for
rehailitation of home	o
ratuities	es
Hoy income	es
Honorariums	es
ndiidual Retirement Arrangement RA
CONVENTIONAL IRA
ayments receied	es
ayments contributed	o
Rolloers or conersions	o
ROTH IRA
ayments receied	o
ayments contributed	es
Rolloers or conersions	o
nheritance	es
rom spouseRho resided with you	o
nsurance roceeds
Accident and health	es
isability payments	es
Employee death benefits	es
fe insurance	es
ersonal inury damages (less
attorney fees)	es
roperty damage if included in
federal income	es
Reimbursement of medical epense	o
icay (employer sicness and
inury pay)	es
trie benefits	es
nemployment compensation	es
orers’ compensation	es
nterestaale and nontaale	es
ontracts	es
unicipal bonds and other securities	es

ings accounts				es
a-eempt interest			es
.. ings onds			es
osses on sales to etent used in
determining A		(limited to ,)	es
From sales of real or sonal
roty nonusiness		...................................		o
ottery winnings				es
umsum distriution less cost
recoery	..........................................................			es
ilitary and eteran’s enefits
taale and nontaale
ombat pay				es
isability pensions				es
Educational benefits (ill)			es
amily allowances				es
ensions	........................................................			es
et oating loss carryacnd carryoer				... o
artnershincome reduced y
enses	(losses limited to ,)		es
arsonage rental aluer housing
allowance in ecess of enses
used in determining federal A				es
ensions and annuities taale and
nontaalereduced y cost
recoered in the current year				es
ries and awards				es
ulic assistance enefits				es
Aid to blind and disabled				es
hild care payments				es
hild support included in public
assistance				es
irect payments to nursing home				o
ood stamps (or cash payments in lieu
of food stamps)				o
uel assistance				o
n-home serices approed by the
epartment of uman erices				o
edical payments to doctors				o
regon upplemental ncome
rogram ()			es
ayments for medical care, drugs,
medical supplies, and serices for
which no direct payment is receied				o
Reimbursements of epenses paid or
incurred by participants in wor
or training programs				o
pecial helter Allowance (A)				o

urplus food			o
emporary assistance to needy families			......... o
omen, nfants, and hildren
program ()			o
Railroad Retirement oard enefits		.........	es
Refunds
Earned income credit			o
ederal ta	...........................................................		o
roperty ta			o
regon income ta			o
ther states’ income ta (if in federal A) ...			es
rior-year rental assistance payment			o
Reimursements in ecess of enses			... es
Rental allowances aid to ministers
not included in federal A			es
Rental and royalty income reduced y
enses	(losses limited to ,)	es
Residence sales see gains on sales		..........	es
Retirement benefits (see pensions and
ocial ecurity)
cholarshis totaling more than 00			.... es
icay			es
ocial curity taale and nontaale			... es
hildren’s benefits paid to parent			es
hildren’s benefits paid to your child			o
isability pension			es
edicare payments of medical epenses			o
edicare premiums deducted from
ocial ecurity			es
ld-age benefits			es
ocial ecurity isability nsurance
()		es
upplemental ecurity ncome ()		es
urior benefits		es
tinds totaling more than 00			es
trie enefits			es
uort from arents who don’t lie
in your household			es
rust income			es
nemloyment comnsation			es
ages			es

rrent mailing address

it	tate	ode	elepone nmer
			(	)

For department se onl

12

Work and investment income—Totals for the entire year
1	ages, salaries, and oter paor wor				1			.00
2	nterest and dividends (total taale and nontaale)			.....................	2			.00
siness net inome (loss limited to 1,000)								.00
4	Farm net inome (loss limited to 1,000)				4			.00
5 otal gain on propertales (loss limited to 1,000)					5			.00
Rental net inome (loss limited to 1,000)								.00
ter inome from or federal retrn. dentif								.00
dd lines		1 through 7						•		.00
Retirement income—Totals for the entire year
9	oial erit, spplemental seritnome (),
	railroad retirement (taale and nontaale)				• 9			.00
10	ensions and annities (see instrtions)				• 10			.00
11	dd lines	9 and 10					11			.00
Other income—Totals for the entire year
12	ildren, dlts, and Families (plissistane,
	not inlding food stamps)				• 12			.00
1Unemploment enefits					• 1			.00
14	eteran’s and militarenefits				14			.00
15	Familpport, gifts, and grantsotal reeived			minus 500	15			.00
1 ter soresdentif					1			.00
1dd lines		12 through 16						• 1		.00
1dd lines		8, 11, and 17							1

19	dstments to inome from federal Form 1040, line		or federal Form 1040, line 20			• 19
20	Your total household income. ine 1ins line 19. f or oseold inome
	is 10,000 or more, STOP HERE oon’t alifor elderlental assistane					• 20
21	Your total household assets. Fill in or total oseold assets from te
	af tis form. (f or or sposeRre age 5 or older, te limitation			s do not
	appl. Fill in -0- on line 21.) f or oseold assets eeed 25,000,			STOP HERE
	oon’t alifor elderlental assistane			• 21			.00
Qualifying rent
22	otal regon rent you paid dring 2010 (from of rent sedle on te a)				• 22
2 peial elter llowane (see page )						• 2
24	otal fel and tilities onlnot telepone).	Don’t include rent (see page 1)					• 24
25	ee of oaid rent to a	nrsing ome	retirementare ome or failit			grop ome

.00

.00

.00

.00

.00

.00

Sign here

➜

or signatre

ate

➜

pose’sR’s signatre (f iling ointl, st sign)

ignatre of preparer oter tan tapaer

iense no.

ddress

4. 2010 rental period

Fromo

Fromo

5. Rent oaid per mont

5

.....................................5

. otal rent oaid (per address) .................

.....................................

rrent mailing address

it	tate	ode	elepone nmer
			(	)

For department se onl

12

Work and investment income—Totals for the entire year
1	ages, salaries, and oter paor wor				1			.00
2	nterest and dividends (total taale and nontaale)			.....................	2			.00
siness net inome (loss limited to 1,000)								.00
4	Farm net inome (loss limited to 1,000)				4			.00
5 otal gain on propertales (loss limited to 1,000)					5			.00
Rental net inome (loss limited to 1,000)								.00
ter inome from or federal retrn. dentif								.00
dd lines		1 through 7						•		.00
Retirement income—Totals for the entire year
9	oial erit, spplemental seritnome (),
	railroad retirement (taale and nontaale)				• 9			.00
10	ensions and annities (see instrtions)				• 10			.00
11	dd lines	9 and 10					11			.00
Other income—Totals for the entire year
12	ildren, dlts, and Families (plissistane,
	not inlding food stamps)				• 12			.00
1Unemploment enefits					• 1			.00
14	eteran’s and militarenefits				14			.00
15	Familpport, gifts, and grantsotal reeived			minus 500	15			.00
1 ter soresdentif					1			.00
1dd lines		12 through 16						• 1		.00
1dd lines		8, 11, and 17							1

19	dstments to inome from federal Form 1040, line		or federal Form 1040, line 20			• 19
20	Your total household income. ine 1ins line 19. f or oseold inome
	is 10,000 or more, STOP HERE oon’t alifor elderlental assistane					• 20
21	Your total household assets. Fill in or total oseold assets from te
	af tis form. (f or or sposeRre age 5 or older, te limitation			s do not
	appl. Fill in -0- on line 21.) f or oseold assets eeed 25,000,			STOP HERE
	oon’t alifor elderlental assistane			• 21			.00
Qualifying rent
22	otal regon rent you paid dring 2010 (from of rent sedle on te a)				• 22
2 peial elter llowane (see page )						• 2
24	otal fel and tilities onlnot telepone).	Don’t include rent (see page 1)					• 24
25	ee of oaid rent to a	nrsing ome	retirementare ome or failit			grop ome

.00

.00

.00

.00

.00

.00

Sign here

➜

or signatre

ate

➜

pose’sR’s signatre (f iling ointl, st sign)

ignatre of preparer oter tan tapaer

iense no.

ddress

4. 2010 rental period

Fromo

Fromo

5. Rent oaid per mont

5

.....................................5

. otal rent oaid (per address) .................

.....................................