PDF document
- 1 -

Enlarge image
1                                                                                                                                                                                                 1
  1  2   2    5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   Form All layers With grid &2 data  84 85
3 4                                                                                                                                                                                               82 83
3                                                                                                                                                                                                 3
4                                                                                                                                                                                                 4
5                                                                                                          Oregon Department of Revenue                                                           5
                      2024 Schedule OR-ADD-DEP
6                     Oregon Individual Income Tax Return Additional Dependents                                                                                                                   6
7                                                                                                                                                                                                 7
8                     Page 1 of 1   • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                                   8
9           Last name                                                                                Social Security number (SSN)                                                                 9
10                                                                                                                                                                                                10
11                                                                                                                                                                                                11
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                         999-99-9999
12                                                                                                                                                                                                12
13          Instructions. Use this schedule if you have more than three dependents. Complete all information for each additional dependent who is not listed                                      13
14          on the second page of your Oregon return. List your dependents in order from youngest to oldest. If you have more than eight dependents, fill out and                                 14
15          include an additional Schedule OR-ADD-DEP.                                                                                                                                            15
16          Dependent 4: First name                          Initial          Dependent 4: Last name                                                                                              16
17                                                                                                                                                                                                17
18                                                                                                                                                                                                18
            XXXXXXXXXXXXXXXX                                 X                XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19          Dependent 4: Date of birth (MM/DD/YYYY)          Dependent 4: SSN                        Code*                                                                                        19
20                                                                                                                                                                                                20
21          99/99/9999/   /                                  999-99-9999                             XX    X    Child with a qualifying disability                                                21
22                                                                                                                                                                                                22
23          Dependent 5: First name                          Initial          Dependent 5: Last name                                                                                              23
24                                                                                                                                                                                                24
25                                                                                                                                                                                                25
            XXXXXXXXXXXXXXXX                                 X                XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
26          Dependent 5: Date of birth (MM/DD/YYYY)          Dependent 5: SSN                        Code*                                                                                        26
27                                                                                                                                                                                                27
28          99/99/9999/   /                                  999-99-9999                             XX    X    Child with a qualifying disability                                                28
29                                                                                                                                                                                                29
30          Dependent 6: First name                          Initial          Dependent 6: Last name                                                                                              30
31                                                                                                                                                                                                31
32                                                                                                                                                                                                32
            XXXXXXXXXXXXXXXX                                 X                XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
33          Dependent 6: Date of birth (MM/DD/YYYY)          Dependent 6: SSN                        Code*                                                                                        33
34                                                                                                                                                                                                34
35          99/99/9999/   /                                  999-99-9999                             XX    X    Child with a qualifying disability                                                35
36                                                                                                                                                                                                36
37          Dependent 7: First name                          Initial          Dependent 7: Last name                                                                                              37
38                                                                                                                                                                                                38
39                                                                                                                                                                                                39
            XXXXXXXXXXXXXXXX                                 X                XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
40          Dependent 7: Date of birth (MM/DD/YYYY)          Dependent 7: SSN                        Code*                                                                                        40
41                                                                                                                                                                                                41
42          99/99/9999/   /                                  999-99-9999                             XX    X    Child with a qualifying disability                                                42
43                                                                                                                                                                                                43
44          Dependent 8: First name                          Initial          Dependent 8: Last name                                                                                              44
45                                                                                                                                                                                                45
46                                                                                                                                                                                                46
            XXXXXXXXXXXXXXXX                                 X                XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
47          Dependent 8: Date of birth (MM/DD/YYYY)          Dependent 8: SSN                        Code*                                                                                        47
48                                                                                                                                                                                                48
49          99/99/9999/   /                                  999-99-9999                             XX    X    Child with a qualifying disability                                                49
50                                                                                                                                                                                                50
51          *Dependent relationship code (see instructions).                                                                                                                                      51
52                                                                                                                                                                                                52
53            6.  Total number of additional dependents listed above. Enter the result here and include this number on line                                                                       53
54             6c of your Oregon return. .................................................................................................................................................. 6. 99 54
55                                                                                                                                                                                                55
56            7.  Total number of additional dependent children with a qualifying disability listed above. Enter the result here                                                                  56
57             and include this number on line 6d of your Oregon return. .............................................................................................. 7.                     99 57
58                                                                                                                                                                                                58
59                                  —You must include this schedule with your Oregon income tax return—                                                                                           59
60                                                                                                                                                                                                60
61                                                                                                                                                                                                61
62                                                                                                                                                                                                62
                      150-101-187
63                    (Rev. 08-08-24, ver. 01)                                                             18372401010000                                                                         63
64                                                                                                                                                                                                64
  1  2   65   5  6  7  8  9  10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81   65                             84 85
3 4                                                                                                                                                                                               82 83
66                                                                                                                                                                                                66






PDF file checksum: 2402348550

(Plugin #1/10.13/13.0)