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5            2022 Schedule OR-EIS                                                                                                                             Office use only       5
6           Page 1 of 2, 150-101-687                        Oregon Department of Revenue                                      02492201010000             Date received              6
7           (Rev. 08-19-22, 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        12
13           XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX                                                                                                      999-99-9999– –                13
14          Street address (not a PO Box)                                                                                City                         State ZIP code                14
15                                                                                                                                                                                  15
16          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXFull name as shown on tribal enrollment                   XXXXXXXXXXXXXXXXXXXXX XXTribal enrollmentXXXXX-XXXXnumber                  16
17                                                                                                                                                                                  17
18          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIndian tribe of which you are an enrolled member                                                       XXXXXXXXXXX                   18
19                                                                                                                                                                                  19
20           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXYour tribal headquarters’ address, city, state, and ZIP                                                                             20
21                                                                                                                                                                                  21
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
22                                                                                                                                                                                  22
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 Social Security number 24
25           XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX                                                                                                      999-99-9999– –                25
26          Spouse street address (not a PO Box)                                                                         City                         State ZIP code                26
27                                                                                                                                                                                  27
28          Spouse full name as shown on tribal enrollmentXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XXSpouse tribal enrollment numberXXXXX-XXXX                     28
29                                                                                                                                                                                  29
30          Indian tribe of which spouse is an enrolled memberXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                     XXXXXXXXXXX                   30
31                                                                                                                                                                                  31
32          Spouse tribal headquarters’ address, city, state, and ZIPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                            32
33                                                                                                                                                                                  33
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
34                                                                                                                                                                                  34
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
39                                                                                                                                                                                  39
40                                                                                                                                                                                  40
41           Your Exempt Income Information                                                                                                                                         41
42           Employer name or source of exempt income                                                                                                                               42
43                                                                                                                                                                                  43
44           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income                                  44
45                                                                                                                                                                                  45
46           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        46
47                                                                                                                                                                                  47
48           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.)                   XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        48
49                                                                                                                                                                                  49
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
50           Amount qualifying as exempt income ....................................................................................................$ 99,999,999,999.99.            50
51                                                                                                                                                                                  51
52           Employer name or source of exempt income                                                                                                                               52
53                                                                                                                                                                                  53
54           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income                                  54
55                                                                                                                                                                                  55
56           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        56
57                                                                                                                                                                                  57
58           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.)                   XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        58
59                                                                                                                                                                                  59
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
60           Amount qualifying as exempt income ....................................................................................................$ 99,999,999,999.99.            60
61                                                                                                                                                                                  61
62                            —Don’t include this schedule with your Oregon return. Keep it with your tax records.—                                                                 62
63                                                                                                                                                                                  63
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71           2022 Schedule OR-EIS                                                                                                                                                   71
72           Page 2 of 2, 150-101-687                 Oregon Department of Revenue                                       02492201020000                                             72
73           (Rev. 08-19-22, ver. 01)                                                                                                                                               73
74                                                                                                                                                                                  74
75           Your Exempt Income Information (Continued from page 1)                                                                                                                 75
76           Employer name or source of exempt income                                                                                                                               76
77                                                                                                                                                                                  77
78           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income                                  78
79                                                                                                                                                                                  79
80           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        80
81                                                                                                                                                                                  81
82           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.)                   XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        82
83                                                                                                                                                                                  83
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
84           Amount qualifying as exempt income ....................................................................................................$          99,999,999,999.99.   84
85                                                                                                                                                                                  85
86           Spouse Exempt Income Information                                                                                                                                       86
87           Employer name or source of exempt income                                                                                                                               87
88                                                                                                                                                                                  88
89           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income                                  89
90                                                                                                                                                                                  90
91           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        91
92                                                                                                                                                                                  92
93           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.)                   XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        93
94                                                                                                                                                                                  94
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
95           Amount qualifying as exempt income ....................................................................................................$          99,999,999,999.99.   95
96                                                                                                                                                                                  96
97           Employer name or source of exempt income                                                                                                                               97
98                                                                                                                                                                                  98
99           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income                                  99
100                                                                                                                                                                                 100
101          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        101
102                                                                                                                                                                                 102
103          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.)                   XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        103
104                                                                                                                                                                                 104
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
105          Amount qualifying as exempt income ....................................................................................................$          99,999,999,999.99.   105
106                                                                                                                                                                                 106
107          Employer name or source of exempt income                                                                                                                               107
108                                                                                                                                                                                 108
109          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP where you worked if wages, unemployment, or retirement income                                  109
110                                                                                                                                                                                 110
111          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXStreet address, city, state, and ZIP code where you lived (not a PO Box) XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        111
112                                                                                                                                                                                 112
113          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXIncome type (wages, interest, gambling winnings, etc.)                   XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX                        113
114                                                                                                                                                                                 114
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
115          Amount qualifying as exempt income ....................................................................................................$          99,999,999,999.99.   115
116                                                                                                                                                                                 116
117          Enter the total of your and/or your spouse’s income that meets all of the requirements above.                                                                          117
118          Round to the nearest dollar.                                                                                                                                           118
119          Claim this amount as a subtraction on Schedule OR-ASC, section B, or OR-ASC-NP, section C,                                                                             119
120          using subtraction code 300 .................................................................................................................... $ 99,999,999,999.00.00 120
121                 —Don’t include this schedule with your Oregon return. Keep it with your tax records.—                                                                           121
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