The Oregon Statement form, officially known as Form OR-SFC, is a critical document used to provide a comprehensive overview of an individual's financial condition. Completing this form accurately is essential, as it serves as a basis for evaluating eligibility for various financial relief options, including suspended collection status. Failure to fill out all sections can lead to continued collection activities, which may result in garnishment or assignment of debt to collection agencies.
The Oregon Statement form, officially known as Form OR-SFC, serves as a vital tool for individuals and businesses navigating their financial obligations in the state of Oregon. This comprehensive form requires users to provide detailed information about their financial condition, including personal and household income, employment details, and various assets and liabilities. By completing all sections accurately, individuals can avoid complications such as continued collection activities, which may lead to garnishment or the assignment of debt to collection agencies. The form asks for essential documentation, such as three months of current bank statements, pay stubs, and profit and loss statements for businesses, ensuring that all financial information is up-to-date. Additionally, it allows applicants to request suspended collection status or modifications to wage garnishments, providing a pathway for those facing financial difficulties. The form is divided into sections that cover personal information, employment details, general financial information, and a thorough asset and liability analysis. Each section plays a crucial role in painting a complete picture of an individual's or business's financial standing, making it an indispensable part of managing financial responsibilities in Oregon.
Form OR-SFC
Statement of Financial Condition
Return by:
Complete all sections of this form. If you don’t complete all sections of this form, we can- not process it, which will continue collection activity. This may result in garnishment, lien, or assignment of debt to a private collection agency.
Three months of current bank statements—personal and business (if applicable). Three months of current pay stubs (if applicable).
Three months of profit and loss statements (for businesses only).
•All household income.
Additional sheets, as needed, for additional information.
Check here if applying for suspended collection status. For suspended collection status qualifications, visit www.oregon.gov/dor and search for “Suspended collection.”
Check here if applying for a wage garnishment modification.
Revenue use only
Date received
Revenue agent
Section 1. Personal information
Your irst name
MI
Last name
Your Social Security number
– –
Your date of birth
Other names or aliases used
Spouse/RDP’s irst
Spouse/RDP’s Social Security number
Spouse/RDP’s date of birth
name
–
Spouse/RDP’s other names or aliases used
Your cell phone
Your driver license number
State
Spouse/RDP’s cell phone
Spouse/RDP’s driver license no.
(
)
Your email
Spouse/RDP’s email
Dependent’s name (living with you)
Date of birth
Social Security number
Relationship
Your current physical address
City
ZIP code
County
Your home phone
()
Your mailing address (if different from above)
Name of your tax representative (CPA, attorney, enrolled agent)
Fax number
Phone
Address of your tax representative
Section 2. Employment information (personal and business)
Your employer or business name
Business phone
Payroll fax
Address
Date hired:____________________
Occupation: _______________________________
Wage earner
Sole proprietor
Partner
Owner oficer
Paid:
Weekly
Every other week
Monthly
Twice a month
Number of allowances claimed on Form W-4:____________________
150-101-159 (Rev. 01-17)
Form OR-SFC, Financial Statement—Page 1
Section 2. (continued) Employment information (personal and business)
Spouse/RDP’s employer or business name
If self-employed: List all responsible owner(s), partner(s), oficer(s), major shareholder(s), etc.
Identify the major responsibilities of each by circling the codes that apply: 1 = Files returns; 2 = Pays taxes; 3 = Prefers creditors; 4 = Hires and ires
Name and title
Effective date
Home address
Home phone
SSN
Code
1
2
3
4
Section 3. General inancial information (personal and business)
Bank accounts. Include IRA and retirement plans certiicates of deposit, etc. For all accounts, attach copies of your last three bank statements. Attach additional pages as needed.
Name of institution
Type
Date opened
Account number
Balance
Total. Enter this amount on line 2, Section 4 (asset and liability analysis)........................
$
Safe deposit boxes (rented or accessed). Include location, box number, and contents. Attach additional pages as needed.
Box identiication
Current value of assets
Total. Enter this amount on line 3, Section 4 (asset and liability analysis)........................
Vehicles. Attach supporting documentation of current payoff. Attach additional pages as needed, and vehicles paid in full.
Year, make, model, license number
Lender/lien holder
Current market value
Current payoff
Available equity
(cannot be less than -0-)
Total. Enter this amount on line 4, section 4 (asset and liability analysis) ........................
Form OR-SFC, Financial Statement—Page 2
Section 3. (continued) General inancial information (personal and business)
Personal property. Include water craft, RVs, air craft, business equipment, and/or machinery. Attach additional pages as needed.
Total. Enter this amount on line 6, section 4 (asset and liability analysis) ........................
Life insurance. Attach additional pages as needed.
Name of insurance company
Agent’s name and phone
Policy number
Face amount
Loan/cash
surrender value
Total. Enter this amount on line 7, section 4 (asset and liability analysis) ........................
Securities. Include stocks, bonds, mutual funds, money market funds, securities, 401(k), etc. Attach additional pages as needed.
Where located
Owner of record
Quantity or denomination
Current value
Total. Enter this amount on line 8, section 4 (asset and liability analysis) ........................
Real property. Include a copy of the deed and a copy of homeowners/rental insurance policy with riders and supporting documentation of loan balance. Attach additional pages as needed.
A. Physical address
(single- or multi-family dwelling,
lot, rental, etc.)
Mortgage lender’s name and address
Parcel number:_______________
How is title held:______________________________________ Purchase price: _________________ Purchase date: __________________
Current market value: _______________________Mortgage balance: ___________________________ Equity: ___________________________
B. Physical address
C. Physical address
Form OR-SFC, Financial Statement—Page 3
D. Physical address
Total Equity. Enter this amount on line 9, Section 4 (asset and liability analysis) . . . . . . . . .
Credit cards and lines of credit. Credit cards and unsecured lines of credit may only be allowed with three months of statements showing they are used for living expenses.
Type of account
Name and address of creditor
Monthly payment
Credit limit
Credit available
Amount owed
Total $
Total. Enter this amount on line 28, Section 4 (asset and liability analysis)
Other inancial information. Please provide the following information relating to your inancial conditions. If you check “Yes” in any box, provide dates, an explanation, and documentation. Attach additional pages as needed.
Court proceedings
No
Yes _______________________________________________________________________________
Repossessions
Anticipated increase in income
Bankruptcies/receiverships
Recent transfer of assets
Beneiciary to trust, estate, proit sharing, etc. ...
Last Oregon income tax return iled
Year:_______ _______________________________________________________________________________
Total number of exemptions claimed
___________ ________________________________________________________________________________
Adjusted gross income from return
$__________ ________________________________________________________________________________
List any vehicles, equipment, or property sold, given away, or repossessed during the past three years. Attach additional pages as needed.
Year, make, model of vehicle, or property address
Who took possession
Value
Form OR-SFC, Financial Statement—Page 4
Section 4. Assets and liability analysis
Immediate assets.
Totals
1.Cash
2.Bank accounts / balance (from section 3)
3.Safe deposit box value of contents (from section 3)
4.Enter vehicles equity (from section 3)
5.Vehicle equity formula (line 4 - $3000, if less than -0-, enter -0-) This line for use on form 150-101-157, Settlement Offer Application only.
6.Personal property (from section 3)
7.Loan / cash surrender value for life insurance (from section 3)
8.Securities (from section 3)
9.Current real estate equity (from section 3)
10.Notes
11.Accounts receivable
12.Judgements / settlements received or pending
13. Interest in trusts
14. Interest in estates
15. Partnership interests
16. Major machinery / equipment, etc.
17. Business inventory
18. Other assets: (specify): (Example: $1,000 guns / $200 jewelry / $800 gold)
19. Other assets (specify):
20. Total assests
Real property equity. From Section 3. Liens or cost of sale don’t reduce equity (can’t be less than -0-).
Address or location
RMV from property tax statement
Mortgage payoff amount
Equity
21.
Property 1:
22.
Property 2:
23.
Property 3:
24. Total equity from properties listed on additional sheet (if applicable)
25.
Total of all real property equity (add the Equity column from lines 21 thru 24)
26. Enter dollar amount from line 20
27. Total value of all immediate assets and real property equity (line 25 plus line 26)
Current liabilities. Include judgements, notes, and other charge accounts. Do not include vehicle or home loans.
28.Amount owed to credit cards and lines of credit (from Section 3)
29.Taxes owed to IRS (provide a copy of recent notices)
30.Other liabilities (specify):
31.Other liabilities (specify):
32.Other liabilities (specify):
33. Total liabilities
Form OR-SFC, Financial Statement—Page 5
Section 5. Monthly income and expense analysis
Income. Attach copies of all income sources that contribute to household expenses (minimum three months).
List Net Income
34.
Wages / salaries / tips (yours)
35. Social Security income (yours)
36.
Pension / annuities (yours)
pension
annuities
both
37.
Disability (yours)
38. Wages / salaries / tips (spouse/RDP’s)
39.Social Security income (spouse/RDP’s)
40.Pension / annuities (spouse/RDP’s) pension annuities both
41.Disability (spouse/RDP’s)
42.Interest / dividends / royalties (average monthly)
43.Payments from trust / partnerships / entities
44.Unemployment
45.Other income (specify)
46.Other income (specify)
47.Other income (specify)
List Gross Income
48. Business income (yours)
49.Business income (spouse/RDP’s)
50.Rental income
51.Child support
52.Alimony
53.Seller carried contracts / sales
54. Total income
Personal expenses (actually paid). (May be limited by federal standards.)
55. Rent / mortgage / real estate secured line(s) of credit
If renting—name, address, and phone number of landlord
Amount
56.
Real estate taxes
(Is this included in your mortgage payment?
Yes)
57. Personal home owners / renters insurance: (
) Assoc. fees: (
58. Personal utilities:
Electric: (
Natural gas / oil: (
Phone, internet, & cable: (
Garbage: (
Water / sewer: (
59.
Food / clothing / other Items: No. of people: (
Their ages: (
60. Auto payments / lease
61.
Auto insurance
62. Auto maintenance / fuel / other transportation
63.Medical payments (not covered by insurance) (provide proof)
64.Estimated tax payments (provide proof)
65.Court ordered payments (alimony, child support, restitution, not deducted from your paycheck)
Form OR-SFC, Financial Statement—Page 6
Section 5. (continued) Monthly income and expense analysis
Personal expenses (actually paid). (continued) (May be limited by federal standards.)
66.Garnishments (specify)
67.Delinquent tax payments (other than Oregon state taxes, IRS, etc.)
68.Work related child care expenses
69. Other expenses (do not include unsecured debt) (specify)
70. Total personal expenses
Business expenses (actually paid). Provide current general ledger and proit / loss.
71. Materials purchased (specify)
72.
Supplies (specify)
73. Installment payments (specify)
74.
Monthly payments (specify)
75. Rent / mortgage
76.
Insurance
77. Business utilities: Electric: (
78.
Net wages and salaries paid to employees
79. Current taxes (payroll / business)
80. Other: Specify: (do not include unsecured debt)
81.
Total business expenses
82. Net disposable income (line 54 minus lines 70 and 81)........................................................................................................
Section 6. Additional information
Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.
Form OR-SFC, Financial Statement—Page 7
Section 6. (continued) Additional information
Your proposed monthly payment.....................................................................................................................
Your proposed payment date...........................................................................................................................................
Section 7. Authorization to disclose
Under penalties of perjury, I declare that I have examined this statement of assets, liabilities, and other information, and to the best of my knowledge and belief, it is true, correct, and complete. I (we) authorize the Oregon Department of Revenue to verify any information on this inancial statement which may include credit reports.
Sign here
X
Your signatureDate
Spouse’s signature (if applying jointly, both must sign even if only one had income)
Date
Return your completed form to: Oregon Department of Revenue
PO Box 14725
Salem OR 97309-5018
Form OR-SFC, Financial Statement—Page 8
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