Oregon Statement Form PDF Details

Are you in the process of formalizing a statement or contract? Whether it's for business use, legal matters, or both, writing an Oregon Statement Form can be essential. This blog post will provide information regarding what an Oregon Statement Form is and its necessary uses. We'll also provide details on how to properly write your own form accurately and effectively so that all parties involved understand their rights and responsibilities. With our helpful tips, you'll be equipped with everything you need to get your paperwork squared away accordingly!

QuestionAnswer
Form NameOregon Statement Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namessfc, statementpage, oregon financial, state of oregon finacial forms

Form Preview Example

Form OR-SFC

Statement of Financial Condition

Return by:

Complete all sections of this form. If you don’t complete all sections of this form, we can- not process it, which will continue collection activity. This may result in garnishment, lien, or assignment of debt to a private collection agency.

Three months of current bank statements—personal and business (if applicable). Three months of current pay stubs (if applicable).

Three months of profit and loss statements (for businesses only).

•All household income.

Additional sheets, as needed, for additional information.

Check here if applying for suspended collection status. For suspended collection status qualifications, visit www.oregon.gov/dor and search for “Suspended collection.”

Check here if applying for a wage garnishment modification.

Revenue use only

Date received

Revenue agent

Section 1. Personal information

Your irst name

MI

Last name

Your Social Security number

– –

Your date of birth

Other names or aliases used

Spouse/RDP’s irst

MI

Last name

 

 

 

Spouse/RDP’s Social Security number

Spouse/RDP’s date of birth

name

 

 

 

 

 

 

 

 

 

–

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/RDP’s other names or aliases used

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your cell phone

 

Your driver license number

 

State

Spouse/RDP’s cell phone

 

Spouse/RDP’s driver license no.

State

(

)

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your email

 

 

 

 

 

 

 

Spouse/RDP’s email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’s name (living with you)

 

 

 

Date of birth

 

 

Social Security number

 

Relationship

 

 

 

 

 

 

 

 

 

 

–

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’s name (living with you)

 

 

 

Date of birth

 

 

Social Security number

 

Relationship

 

 

 

 

 

 

 

 

 

 

–

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’s name (living with you)

 

 

 

Date of birth

 

 

Social Security number

 

Relationship

 

 

 

 

 

 

 

 

 

 

–

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your current physical address

City

State

ZIP code

County

Your home phone

()

Your mailing address (if different from above)

 

City

 

State

ZIP code

 

 

 

 

 

 

Name of your tax representative (CPA, attorney, enrolled agent)

Fax number

 

Phone

 

 

(

 

)

(

)

Address of your tax representative

City

State

ZIP code

Section 2. Employment information (personal and business)

Your employer or business name

Business phone

Payroll fax

 

(

)

(

)

 

Address

City

 

 

State

ZIP code

 

 

 

 

 

 

 

 

Date hired:____________________

Occupation: _______________________________

Wage earner

Sole proprietor

Partner

Owner oficer

Paid:

Weekly

Every other week

Monthly

Twice a month

Number of allowances claimed on Form W-4:____________________

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 1

Section 2. (continued) Employment information (personal and business)

Spouse/RDP’s employer or business name

Business phone

Payroll fax

 

(

)

(

)

 

 

 

 

 

 

 

 

Address

City

 

 

State

ZIP code

 

 

 

 

 

 

 

 

Date hired:____________________

Occupation: _______________________________

Wage earner

Sole proprietor

Partner

Owner oficer

Paid:

Weekly

Every other week

Monthly

Twice a month

Number of allowances claimed on Form W-4:____________________

If self-employed: List all responsible owner(s), partner(s), oficer(s), major shareholder(s), etc.

Identify the major responsibilities of each by circling the codes that apply: 1 = Files returns; 2 = Pays taxes; 3 = Prefers creditors; 4 = Hires and ires

 

Name and title

Effective date

Home address

Home phone

SSN

Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3. General inancial information (personal and business)

Bank accounts. Include IRA and retirement plans certiicates of deposit, etc. For all accounts, attach copies of your last three bank statements. Attach additional pages as needed.

Name of institution

Address

Type

Date opened

Account number

Balance

Total. Enter this amount on line 2, Section 4 (asset and liability analysis)........................

$

Safe deposit boxes (rented or accessed). Include location, box number, and contents. Attach additional pages as needed.

Name of institution

Address

Box identiication

Current value of assets

Total. Enter this amount on line 3, Section 4 (asset and liability analysis)........................

$

Vehicles. Attach supporting documentation of current payoff. Attach additional pages as needed, and vehicles paid in full.

Year, make, model, license number

Lender/lien holder

Current market value

Current payoff

Available equity

(cannot be less than -0-)

Total. Enter this amount on line 4, section 4 (asset and liability analysis) ........................

$

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 2

Section 3. (continued) General inancial information (personal and business)

Personal property. Include water craft, RVs, air craft, business equipment, and/or machinery. Attach additional pages as needed.

Year, make, model, license number

Lender/lien holder

Current market value

Current payoff

Available equity

(cannot be less than -0-)

Total. Enter this amount on line 6, section 4 (asset and liability analysis) ........................

$

Life insurance. Attach additional pages as needed.

Name of insurance company

Agent’s name and phone

Policy number

Type

 

 

Face amount

Loan/cash

surrender value

Total. Enter this amount on line 7, section 4 (asset and liability analysis) ........................

$

Securities. Include stocks, bonds, mutual funds, money market funds, securities, 401(k), etc. Attach additional pages as needed.

Type

Where located

Owner of record

Quantity or denomination

Current value

Total. Enter this amount on line 8, section 4 (asset and liability analysis) ........................

$

Real property. Include a copy of the deed and a copy of homeowners/rental insurance policy with riders and supporting documentation of loan balance. Attach additional pages as needed.

A. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

B. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

C. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 3

Section 3. (continued) General inancial information (personal and business)

D. Physical address

Type

(single- or multi-family dwelling,

lot, rental, etc.)

Mortgage lender’s name and address

Parcel number:_______________

How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________

Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________

Total Equity. Enter this amount on line 9, Section 4 (asset and liability analysis) . . . . . . . . .

$

Credit cards and lines of credit. Credit cards and unsecured lines of credit may only be allowed with three months of statements showing they are used for living expenses.

Type of account

Name and address of creditor

Monthly payment

Credit limit

Credit available

Amount owed

Total $

 

 

 

 

 

Total. Enter this amount on line 28, Section 4 (asset and liability analysis)

 

$

 

 

Other inancial information. Please provide the following information relating to your inancial conditions. If you check “Yes” in any box, provide dates, an explanation, and documentation. Attach additional pages as needed.

Court proceedings

No

Yes _______________________________________________________________________________

Repossessions

No

Yes _______________________________________________________________________________

Anticipated increase in income

No

Yes _______________________________________________________________________________

Bankruptcies/receiverships

No

Yes _______________________________________________________________________________

Recent transfer of assets

No

Yes _______________________________________________________________________________

Beneiciary to trust, estate, proit sharing, etc. ...

No

Yes _______________________________________________________________________________

Last Oregon income tax return iled

Year:_______ _______________________________________________________________________________

Total number of exemptions claimed

___________ ________________________________________________________________________________

Adjusted gross income from return

$__________ ________________________________________________________________________________

List any vehicles, equipment, or property sold, given away, or repossessed during the past three years. Attach additional pages as needed.

Year, make, model of vehicle, or property address

Who took possession

Value

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 4

Section 4. Assets and liability analysis

Immediate assets.

Totals

1.Cash

2.Bank accounts / balance (from section 3)

3.Safe deposit box value of contents (from section 3)

4.Enter vehicles equity (from section 3)

5.Vehicle equity formula (line 4 - $3000, if less than -0-, enter -0-) This line for use on form 150-101-157, Settlement Offer Application only.

6.Personal property (from section 3)

7.Loan / cash surrender value for life insurance (from section 3)

8.Securities (from section 3)

9.Current real estate equity (from section 3)

10.Notes

11.Accounts receivable

12.Judgements / settlements received or pending

13. Interest in trusts

14. Interest in estates

15. Partnership interests

16. Major machinery / equipment, etc.

17. Business inventory

18. Other assets: (specify): (Example: $1,000 guns / $200 jewelry / $800 gold)

19. Other assets (specify):

20. Total assests

$

Real property equity. From Section 3. Liens or cost of sale don’t reduce equity (can’t be less than -0-).

 

Address or location

RMV from property tax statement

Mortgage payoff amount

Equity

Totals

21.

Property 1:

 

 

 

 

22.

Property 2:

 

 

 

 

23.

Property 3:

 

 

 

 

24. Total equity from properties listed on additional sheet (if applicable)

 

 

 

 

25.

Total of all real property equity (add the Equity column from lines 21 thru 24)

 

 

 

 

 

 

 

26. Enter dollar amount from line 20

 

 

 

 

 

 

 

 

 

 

 

27. Total value of all immediate assets and real property equity (line 25 plus line 26)

 

$

 

 

 

Current liabilities. Include judgements, notes, and other charge accounts. Do not include vehicle or home loans.

28.Amount owed to credit cards and lines of credit (from Section 3)

29.Taxes owed to IRS (provide a copy of recent notices)

30.Other liabilities (specify):

31.Other liabilities (specify):

32.Other liabilities (specify):

33. Total liabilities

$

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 5

Section 5. Monthly income and expense analysis

Income. Attach copies of all income sources that contribute to household expenses (minimum three months).

List Net Income

 

 

Totals

34.

Wages / salaries / tips (yours)

 

 

 

 

 

 

 

35. Social Security income (yours)

 

 

 

 

 

 

 

 

36.

Pension / annuities (yours)

pension

annuities

both

 

 

 

 

 

37.

Disability (yours)

 

 

 

 

 

 

38. Wages / salaries / tips (spouse/RDP’s)

 

 

39.Social Security income (spouse/RDP’s)

40.Pension / annuities (spouse/RDP’s) pension annuities both

41.Disability (spouse/RDP’s)

42.Interest / dividends / royalties (average monthly)

43.Payments from trust / partnerships / entities

44.Unemployment

45.Other income (specify)

46.Other income (specify)

47.Other income (specify)

List Gross Income

48. Business income (yours)

49.Business income (spouse/RDP’s)

50.Rental income

51.Child support

52.Alimony

53.Seller carried contracts / sales

54. Total income

$

Personal expenses (actually paid). (May be limited by federal standards.)

55. Rent / mortgage / real estate secured line(s) of credit

If renting—name, address, and phone number of landlord

Amount

56.

Real estate taxes

(Is this included in your mortgage payment?

No

Yes)

 

57. Personal home owners / renters insurance: (

 

) Assoc. fees: (

 

)

58. Personal utilities:

Electric: (

)

 

 

 

 

 

Natural gas / oil: (

)

Phone, internet, & cable: (

)

 

 

Garbage: (

)

 

Water / sewer: (

)

59.

Food / clothing / other Items: No. of people: (

)

Their ages: (

 

)

60. Auto payments / lease

 

 

 

 

 

61.

Auto insurance

 

 

 

 

 

 

62. Auto maintenance / fuel / other transportation

 

 

 

 

 

63.Medical payments (not covered by insurance) (provide proof)

64.Estimated tax payments (provide proof)

65.Court ordered payments (alimony, child support, restitution, not deducted from your paycheck)

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 6

Section 5. (continued) Monthly income and expense analysis

Personal expenses (actually paid). (continued) (May be limited by federal standards.)

Amount

66.Garnishments (specify)

67.Delinquent tax payments (other than Oregon state taxes, IRS, etc.)

68.Work related child care expenses

69. Other expenses (do not include unsecured debt) (specify)

70. Total personal expenses

$

Business expenses (actually paid). Provide current general ledger and proit / loss.

Amount

71. Materials purchased (specify)

 

 

 

 

 

 

 

 

 

 

72.

Supplies (specify)

 

 

 

 

 

 

 

 

 

73. Installment payments (specify)

 

 

 

 

 

 

 

 

 

 

74.

Monthly payments (specify)

 

 

 

 

 

 

 

 

 

75. Rent / mortgage

 

 

 

 

 

 

 

 

 

If renting—name, address, and phone number of landlord

 

 

 

 

 

 

 

 

 

 

76.

Insurance

 

 

 

 

 

 

 

 

 

77. Business utilities: Electric: (

)

 

 

 

 

 

 

 

 

 

 

Natural gas / oil: (

)

Phone, internet, & cable: (

)

 

 

 

 

 

 

 

 

Garbage: (

)

Water / sewer: (

)

 

 

 

 

 

 

 

78.

Net wages and salaries paid to employees

 

 

 

 

 

 

 

 

 

79. Current taxes (payroll / business)

 

 

 

 

 

 

 

 

 

80. Other: Specify: (do not include unsecured debt)

 

 

 

 

 

 

 

 

 

 

81.

Total business expenses

 

 

$

 

 

 

 

 

 

82. Net disposable income (line 54 minus lines 70 and 81)........................................................................................................

$

Section 6. Additional information

Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 7

Section 6. (continued) Additional information

Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.

Your proposed monthly payment.....................................................................................................................

$

Your proposed payment date...........................................................................................................................................

Section 7. Authorization to disclose

Under penalties of perjury, I declare that I have examined this statement of assets, liabilities, and other information, and to the best of my knowledge and belief, it is true, correct, and complete. I (we) authorize the Oregon Department of Revenue to verify any information on this inancial statement which may include credit reports.

Sign here

X

Your signatureDate

X

Spouse’s signature (if applying jointly, both must sign even if only one had income)

Date

Return your completed form to: Oregon Department of Revenue

PO Box 14725

Salem OR 97309-5018

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 8

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The best way to fill in rentingname portion 1

2. The next step is to complete the next few fields: Your cell phone Your email, Your driver license number, State, SpouseRDPs cell phone, SpouseRDPs driver license no, State, SpouseRDPs email, Dependents name living with you, Date of birth, Social Security number, Relationship, Dependents name living with you, Date of birth, Social Security number, and Dependents name living with you.

Part no. 2 in filling in rentingname

3. In this particular part, have a look at Section Employment information, Address, Business phone, Payroll fax, City, State, ZIP code, Date hired Occupation, Wage earner, Sole proprietor, Partner, Owner oficer, Paid, Weekly, and Every other week. All of these should be filled in with greatest accuracy.

Stage no. 3 for filling out rentingname

It's easy to get it wrong while filling in your Partner, and so make sure to reread it before you'll finalize the form.

4. The fourth part comes next with all of the following blank fields to complete: Section continued Employment, Business phone, Address, City, Payroll fax, State, ZIP code, Date hired Occupation, Wage earner, Sole proprietor, Partner, Owner oficer, Paid, Weekly, and Every other week.

rentingname conclusion process clarified (part 4)

5. Finally, the following final part is precisely what you will have to finish before closing the form. The blank fields under consideration include the next: Total Enter this amount on line, Safe deposit boxes rented or, Name of institution, Address, Box identiication, Current value of assets, Total Enter this amount on line, Vehicles Attach supporting, Year make model license number, Lenderlien holder, Current market value, Current payoff, Available equity, and cannot be less than.

Filling out segment 5 of rentingname

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