Form 150-101-024 "Low-Income Caregiver Credit" - Oregon

What Is Form 150-101-024?

This is a legal form that was released by the Oregon Department of Revenue - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2015;
  • The latest edition provided by the Oregon Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 150-101-024 by clicking the link below or browse more documents and templates provided by the Oregon Department of Revenue.

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Download Form 150-101-024 "Low-Income Caregiver Credit" - Oregon

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Clear Form
Low-Income Caregiver Credit
00311501010000
For home care of a low-income person age 60 or older
Your first name and initial
Your last name
Your Social Security number (SSN)
Spouse’s first name and initial (if a joint return)
Spouse’s last name
Spouse’s Social Security number
Your home address where the care was provided (include city, state, and ZIP code)
General instructions
The person you care for must be certified by the Department of Human Services. To do this, fill in Part I of this form. Send it to: Seniors
and People with Disabilities, Department of Human Services, 500 Summer St NE, E02, Salem OR 97301-1073. The form will be returned
to you showing whether the person you care for is certified. If the person you care for is already certified, fill in Part II on the back of
this form. Note: to qualify for the credit, your household income must be less than $17,500 and the person you care for must
have household income of $7,500 or less.
Part I
The questions below are about the person you care for.
1. Name
Birth year
SSN
2. Did the person stay in a nursing home, rehabilitation facility, or other long-term care facility during the year?
Yes
No
If yes, list the dates
3. Did the person receive home care services from Oregon Project Independence during the year?
Yes
No
If yes, list the dates
4. Did the person receive any medical assistance from Seniors and People with Disabilities during the year?
Yes
No
If yes, list the dates
5. Check any of the following conditions that exist for the person you care for during the year:
A. Problems with communication. These include severely limited vision, hearing, speaking, or ability to identify oneself to others.
B. Problems with mobility. These include having great difficulty in traveling inside or outside the home even with a cane, walker,
or wheelchair.
C. Problems with managing a household or nutrition. These include having great difficulty in doing housekeeping, shopping,
or following a special diet.
D. Problems with maintaining personal independence or relationships. These include great difficulty in handling changes,
personal problems, and emotional situations. It also includes great difficulties with friends and living arrangements.
E. Problems with managing money. These include being unable to write checks, pay bills, or keep expenses within income.
F. Problems with health. These include several medical problems requiring regular visits with a doctor or nurse. It also includes
being unable to take prescribed medicine.
G. Problems with personal care tasks. These include bathing, toileting, dressing, and feeding.
6. Based on the condition(s) you checked above, would the person you care for normally be placed in a nursing home?
Yes
No
If yes, during which months did the condition(s) exist?
X
I certify that the above questions were answered truthfully to the best of my knowledge.
Taxpayer’s signature
For official department use only
Certified:
Total tax year 20
Reason:
Partial tax year 20
Not certified
Authorized signature
X
Dates:
150-101-024 (Rev. 12-15)
Clear Form
Low-Income Caregiver Credit
00311501010000
For home care of a low-income person age 60 or older
Your first name and initial
Your last name
Your Social Security number (SSN)
Spouse’s first name and initial (if a joint return)
Spouse’s last name
Spouse’s Social Security number
Your home address where the care was provided (include city, state, and ZIP code)
General instructions
The person you care for must be certified by the Department of Human Services. To do this, fill in Part I of this form. Send it to: Seniors
and People with Disabilities, Department of Human Services, 500 Summer St NE, E02, Salem OR 97301-1073. The form will be returned
to you showing whether the person you care for is certified. If the person you care for is already certified, fill in Part II on the back of
this form. Note: to qualify for the credit, your household income must be less than $17,500 and the person you care for must
have household income of $7,500 or less.
Part I
The questions below are about the person you care for.
1. Name
Birth year
SSN
2. Did the person stay in a nursing home, rehabilitation facility, or other long-term care facility during the year?
Yes
No
If yes, list the dates
3. Did the person receive home care services from Oregon Project Independence during the year?
Yes
No
If yes, list the dates
4. Did the person receive any medical assistance from Seniors and People with Disabilities during the year?
Yes
No
If yes, list the dates
5. Check any of the following conditions that exist for the person you care for during the year:
A. Problems with communication. These include severely limited vision, hearing, speaking, or ability to identify oneself to others.
B. Problems with mobility. These include having great difficulty in traveling inside or outside the home even with a cane, walker,
or wheelchair.
C. Problems with managing a household or nutrition. These include having great difficulty in doing housekeeping, shopping,
or following a special diet.
D. Problems with maintaining personal independence or relationships. These include great difficulty in handling changes,
personal problems, and emotional situations. It also includes great difficulties with friends and living arrangements.
E. Problems with managing money. These include being unable to write checks, pay bills, or keep expenses within income.
F. Problems with health. These include several medical problems requiring regular visits with a doctor or nurse. It also includes
being unable to take prescribed medicine.
G. Problems with personal care tasks. These include bathing, toileting, dressing, and feeding.
6. Based on the condition(s) you checked above, would the person you care for normally be placed in a nursing home?
Yes
No
If yes, during which months did the condition(s) exist?
X
I certify that the above questions were answered truthfully to the best of my knowledge.
Taxpayer’s signature
For official department use only
Certified:
Total tax year 20
Reason:
Partial tax year 20
Not certified
Authorized signature
X
Dates:
150-101-024 (Rev. 12-15)
Part II
Household income
00311501020000
List your household income and the household income of the person you care for in the space below. Household income is the taxable
and nontaxable income of both spouses (living in the same household). See the Elderly Rental Assistance (ERA) Form 90R instructions
for more information on household income.
Your
Household income of
Type of income
household income
person you care for
1. Wages, salaries, and other pay for work .......................
1a.
1b.
2. Interest, dividends (total taxable and nontaxable) ........
2a.
2b.
3. Business net income (loss limited to $1,000) ................
3a.
3b.
4. Total gain on property sales (loss limited to $1,000) .....
4a.
4b.
5. Social Security, SSI, and Railroad Retirement ..............
5a.
5b.
6. Pensions, annuities (taxable and nontaxable) ...............
6a.
6b.
7. Children, Adult, and Families (public assistance) .........
7a.
7b.
8. Gifts and grants over $500 ............................................
8a.
8b.
9. Other (specify) ................................................................
9a.
9b.
10. Total household income ............................................. 10a.
10b.
If your household income is $17,500 or more, or if the person you care for has household income of more than $7,500, you aren’t
eligible for the credit.
11. You may claim food, clothing, medical, and transportation expenses you pay or incur for the person you care for. The expenses
must be paid or incurred during the period of care certified by the Seniors and People with Disabilities Division. Amounts you
pay for lodging don’t qualify. Subtract any reimbursement you received from insurance or from the person you care for when you
figure the costs you paid.
A. Food ................................................................................................................. $
B. Clothing (includes cost of purchase, cleaning, and repairing) ....................... $
C. Medical care (includes doctor fees, medicine, special equipment, etc.) ....... $
D. Transportation (includes transportation for medical and personal needs) .... $
12. Total expenses you paid (add the amounts on lines A, B, C, and D) ........................................... 12.
Note: The expenses you paid for the person you care for are considered a gift. The amount
you paid over $500 must be included in their household income. If the amount on line 12 is
more than $500, include the excess on line 8b.
13. Multiply the amount on line 12 x 0.08 (8 percent) ........................................................................ 13.
14. Maximum credit ............................................................................................................................ 14.
$250
15. Allowable credit (lesser of line 13 or line 14). Enter result here and on section 3 of
Oregon Schedule OR-ASC using code 805. ................................................................................ 15.
Don’t attach this form to your Oregon return. Keep it with your tax records.
150-101-024 (Rev. 12-15)
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