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5 2023 Schedule OR-EIS Office use only 5
6 Page 1 of 2, 150-101-687 Oregon Department of Revenue 02492301010000 Date received 6
7 (Rev. 08-18-23, ver. 01) 7
8 Exempt Income Schedule for Enrolled Members of a Federally 8
9 Recognized Indian Tribe 9
10 10
11 Submit original form—do not submit photocopy. 11
12 First name Initial Last name Social Security number (SSN) 12
13 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 13
14 Street address (not a PO Box) City State ZIP code 14
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16 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXFull name as shown on tribal enrollment XXXXXXXXXXXXXXXXXXXXX XXTribal enrollmentXXXXX-XXXXnumber 16
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18 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIndian tribe of which you are an enrolled member XXXXXXXXXXX 18
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20 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXYour tribal headquarters’ address, city, state, and ZIP 20
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
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23 If you are filing a joint return and your spouse’s income meets the exempt income requirements, fill in the requested information below. 23
24 Spouse first name Initial Spouse last name Spouse SSN 24
25 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX 999-99-9999– – 25
26 Spouse street address (not a PO Box) City State ZIP code 26
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28 Spouse full name as shown on tribal enrollmentXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XXSpouse tribal enrollment numberXXXXX-XXXX 28
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30 Indian tribe of which spouse is an enrolled memberXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX 30
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32 Spouse tribal headquarters’ address, city, state, and ZIPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 32
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
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35 You will not have to pay Oregon income tax on income that meets all of the following requirements: 35
36 • The income is earned by an enrolled member of a federally recognized American Indian tribe; and 36
37 • The income comes from sources within the boundaries of federally recognized Indian country in Oregon; and 37
38 • The enrolled member lived on federally recognized Indian country in Oregon when the income was earned. 38
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41 Your Exempt Income Information 41
42 Employer name or source of exempt income 42
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44 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income 44
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46 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 46
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48 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 48
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
50 Amount qualifying as exempt income ....................................................................................................$ 99,999,999,999.99. 50
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52 Employer name or source of exempt income 52
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54 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income 54
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56 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 56
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58 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX 58
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
60 Amount qualifying as exempt income ....................................................................................................$ 99,999,999,999.99. 60
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62 —Don’t include this schedule with your Oregon return. Keep it with your tax records.— 62
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