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5 Oregon Department of Revenue 5
2022 Schedule OR-ADD-DEP
6 Oregon Individual Income Tax Return Additional Dependents 6
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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
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 999-99-9999
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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
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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
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23 Dependent 5: First name Initial Dependent 5: Last name 23
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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
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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
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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
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44 Dependent 8: First name Initial Dependent 8: Last name 44
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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
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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
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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
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59 —You must include this schedule with your Oregon income tax return— 59
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150-101-187
63 (Rev. 08-18-22, ver. 01) 18372201010000 63
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