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 2023 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 that 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 Dependent 4: Check if child 20 21 99/99/9999/ / 999-99-9999 XX X has 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 Dependent 5: Check if child 27 28 99/99/9999/ / 999-99-9999 XX X has 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 Dependent 6: Check if child 34 35 99/99/9999/ / 999-99-9999 XX X has 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 Dependent 7: Check if child 41 42 99/99/9999/ / 999-99-9999 XX X has 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 Dependent 8: Check if child 48 49 99/99/9999/ / 999-99-9999 XX X has 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 6c of 53 54 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. 08-14-23, ver. 01) 18372301010000 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 |