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Deceased |
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– |
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Spouse’s/RDP’s last name if joint return |
Spouse’s/RDP’s irst name and initial if joint return Spouse’s/RDP’s SSN if joint return |
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Date of birth (mm/dd/yyyy) |
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Deceased |
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– |
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Current mailing address |
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Telephone number |
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( |
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City |
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State |
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ZIP code |
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Country |
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If you filed a return last year, and your |
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name or address is different, check here |
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•Filing |
1 |
Single |
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Exemptions |
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• |
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• |
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Status 2a |
Married iling jointly |
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Total |
Check |
2b |
Registered domestic partners (RDP) iling jointly |
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6a Yourself |
Regular |
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...... Severely disabled |
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only |
3a |
Married iling separately: |
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one |
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Spouse’s name _____________________________ Spouse’s SSN___________________ |
6b Spouse/RDP ... |
Regular |
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...... Severely disabled |
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......b |
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box |
3b |
Registered domestic partner iling separately: |
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6c All dependents First names __________________________________• c |
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Partner’s name _____________________________ Partner’s SSN ___________________ |
6d Disabled |
First names __________________________________• d |
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4 |
Head of household: Person who qualiies you ________________________________ |
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children only |
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Total •6e |
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5 |
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Qualifying widow(er) with dependent child |
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(see instructions) |
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7a |
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• |
• |
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7b |
• You |
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7c • You have |
7d |
You filed |
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Check all that apply ➛ |
You were: |
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65 or older |
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Blind |
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filed an |
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federal |
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Oregon |
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Spouse/RDP was: |
65 or older |
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Blind |
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extension |
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Form 8886 |
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Form 24 |
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Federal column (F) |
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Oregon column (S) |
INCOME |
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8 |
Wages, salaries, and other pay for work. Include all Forms W-2 |
8F |
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.00 |
• 8S |
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.00 |
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9 |
Taxable interest income from federal Form 1040, line 8a |
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9F |
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.00 |
• 9S |
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.00 |
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10 |
Dividend income from federal Form 1040, line 9a |
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10F |
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.00 |
•10S |
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.00 |
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11 |
State and local income tax refunds from federal Form 1040, line 10 |
11F |
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.00 |
•11S |
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.00 |
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12 |
Alimony received from federal Form 1040, line 11 |
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12F |
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.00 |
•12S |
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Include |
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13 |
Business income or loss from federal Form 1040, line 12 |
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13F |
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.00 |
•13S |
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.00 |
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proof of |
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14 |
Capital gain or loss from federal Form 1040, line 13 |
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14F |
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.00 |
•14S |
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.00 |
withholding |
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15 |
Other gains or losses from federal Form 1040, line 14 |
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15F |
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.00 |
•15S |
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.00 |
(W-2s, |
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1099s), |
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16 |
IRA distributions from federal Form 1040, line 15b |
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16F |
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.00 |
•16S |
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.00 |
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payment, |
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17 |
Pensions and annuities from federal Form 1040, line 16b |
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17F |
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.00 |
•17S |
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.00 |
and payment |
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18 |
Rents, royalties, partnerships, etc., from federal Form 1040, line 17 |
18F |
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.00 |
•18S |
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.00 |
voucher |
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19 |
Farm income or loss from federal Form 1040, line 18 |
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19F |
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.00 |
•19S |
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.00 |
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20 |
Unemployment and other income from federal Form 1040, lines 19 through 21 ... |
20F |
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.00 |
•20S |
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.00 |
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21 |
Total income. Add lines 8 through 20 |
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• 21F |
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.00 |
•21S |
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.00 |
ADJUSTMENTS |
22 |
IRA or SEP and SIMPLE contributions, federal Form 1040, lines 28 and 32 |
22F |
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.00 |
•22S |
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.00 |
TO INCOME |
23 |
Education deductions from federal Form 1040, lines 23, 33, and 34 |
23F |
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.00 |
•23S |
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.00 |
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24 |
Moving expenses from federal Form 1040, line 26 |
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24F |
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.00 |
•24S |
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.00 |
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25 |
Deduction for self-employment tax from federal Form 1040, line 27 |
25F |
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.00 |
•25S |
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.00 |
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26 |
Self-employed health insurance deduction from federal Form 1040, line 29 |
26F |
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.00 |
•26S |
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.00 |
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27 |
Alimony paid from federal Form 1040, line 31a |
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27F |
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.00 |
•27S |
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.00 |
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28 |
Other adjustments to income. Identify: |
•28x |
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•28y |
$ |
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Schedule28z |
• 28F |
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.00 |
•28S |
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.00 |
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29 |
Total adjustments to income. Add lines 22 through 28 |
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• 29F |
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.00 |
•29S |
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.00 |
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30 |
Income after adjustments. Line 21 minus line 29 |
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• 30F |
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.00 |
•30S |
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.00 |
ADDITIONS |
31 |
Interest on state and local government bonds outside of Oregon |
• 31F |
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.00 |
•31S |
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.00 |
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32 |
Federal election on interest and dividends of a minor child |
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• 32F |
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.00 |
•32S |
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.00 |
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33 |
Other additions. Identify: •33x |
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•33y |
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$ |
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Schedule included 33z |
• 33F |
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.00 |
•33S |
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.00 |
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34 |
Total additions. Add lines 31 through 33 |
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• 34F |
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.00 |
•34S |
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.00 |
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35 |
Income after additions. Add lines 30 and 34 |
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• 35F |
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.00 |
•35S |
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.00 |
SUBTRACTIONS |
36 |
Social Security and tier 1 Railroad Retirement Board benefits included on line 20F .. |
• 36F |
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.00 |
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37 |
Other subtractions. Identify: •37x |
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•37y |
$ |
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Schedule included |
37z |
• 37F |
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.00 |
•37S |
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.00 |
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• 38F |
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•38S |
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38 |
Income after subtractions. Line 35 minus lines 36 and 37 |
................................. |
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.00 |
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.00 |
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39 |
Oregon percentage. Line 38S ÷ line 38F (not more than 100.0%) •39 |
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__ __ __.__ % |
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➤ Carry this ➤ |
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amount to line 40 |
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150-101-055 (Rev. 12-12) |
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NOW GO TO THE BACK OF THE FORM ➛ |