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Form OR-PTDA For official use only
Date received at county Date received at Revenue
Page 1 of 3, 150-490-014 17492301010000
(Rev. 07-25-22 ver. 01)
2023 Property Tax Deferral Application
(ORS 311.666-701) Oregon Department of Revenue

Complete this application in full and attach a copy of your 2022–23 property tax statement and, if
applicable, your Social Security Disability award letter (see instructions). File your completed ap-
plication with the county assessor’s office after January 1 and by April 17. See the instructions for
more information.

Applicant section
Type of applicant Individual* *If individual applicant: Are you married? No Yes Spouse’s name/SSN: _____________________________________
Joint spouse Joint other Refiling as surviving spouse. Spouse’s SSN/Deferral account number: ___________________________________________
Downsizing Add a spouse Filing as a disabled heir
Applicant’s name (last, first, MI) Social Security number (SSN) Date of birth Age on April 15 Are you disabled?
– – Yes No
Joint applicant’s name (last, first, MI) Spouse Other Joint applicant’s SSN Date of birth Age on April 15 Are you disabled?
– – Yes No
Current residence address (where you currently receive your mail) City State ZIP code
OR
Property’s physical address City State ZIP code
OR
If property’s physical address is different than your current residence, explain why:

Phone Email

Additional family or friend’s name

Family or friend’s phone Family or friend’s email

If you own a manufactured structure (mobile home), complete this section:
Model year Make Home ID number Serial number

1. Have you previously been approved for Property Tax Deferral on this property? ............. Yes No
If yes, was this property under the program prior to 2011? .............................................. Yes No
2. Does your property contain multiple units? Yes No If yes, how many units?_______________
What is the purpose of the other unit(s)? ________________________________________________________________________
Describe which homestead (unit) you live in _____________________________________________________________________
3. As of April 15, 2023, how many years have you owned the home? _______________ years
As of April 15, 2023, how many years have you lived in the home? _______________ years
If your answer to either of the above questions is less than five years, see Form OR-PDTA Instructions. If you have been on
deferral and feel you meet the criteria for the Downsizing Provision, contact us for the Downsizing Provision worksheet.
4. Do you have a reverse mortgage that is secured by this home? ...................................... Yes No
If you answered “yes,” to the above question Stop here, and refer to Form OR-RMI for further instructions before you
complete your application.
5. Is the home insured for fire and other casualty? ............................................................... Yes No
If your answer to the above question is no, Stop here. You don’t qualify for the Property Tax Deferral program.
Insurance carrier (Required) Policy number (Required)

6. Is the property owned in a trust? ....................................................................................... Yes No
If yes, attach a copy of the trust documents.
7. Do you owe prior years’ property taxes? Yes (See Delay of Foreclosure application) No

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17492301020000
Form OR-PTDA
Oregon Department of Revenue
Page 2 of 3, 150-490-014
(Rev. 07-25-22 ver. 01)
Applicant’s last name First name and MI SSN
– –
Joint applicant’s last name Joint applicant’s first name and MI Joint applicant’s SSN
– –

Annual 2022 combined household income worksheet (Required)

1. Wages, salaries, and other pay for work ............................................................ 1 00
2. Interest and dividends (total taxable and nontaxable)........................................ 2 00
3. Business net income (loss limited to $1,000) ..................................................... 3 00
4. Farm net income (loss limited to $1,000) ........................................................... 4 00
5. Total gain on property sales (loss limited to $1,000) .......................................... 5 00
6. Rental net income (loss limited to $1,000) ......................................................... 6 00
7. Other capital gains (such as, stocks and bonds) (loss limited to $1,000) .......... 7 00
8. Total Social Security, Supplemental Security Income (SSI), and railroad
retirement before Medicare premium deductions ................................................ 8 00
9. Pensions and annuities before health insurance premium
deductions (total taxable and nontaxable) ......................................................... 9 00
10. Unemployment benefits ..................................................................................... 10 00
11. Child support ...................................................................................................... 11 00
12. Veteran’s and military benefits ............................................................................ 12 00
13. Gambling winnings ............................................................................................. 13 00
14. All other sources. Identify: ______________________________________............. 14 00
15. Your total household income. Add lines 1–14 ................................................................................... • 15 00
If your 2022 total household income (line 15) is more than $55,500, Stop here. You don’t qualify for the Property Tax Deferral program.

Net worth asset worksheet ($500,000 limit, not including your home)
1. Cash, savings, and checking account balances as of Dec. 31, 2022 ................. 1 00
2. Amount of investments in retirement plans and
individual retirement accounts as of Dec. 31, 2022 ............................................ 2 00
3. Net worth of other investments as of Dec. 31, 2022 ........................................... 3 00
(Net worth means current value minus debt. Investments include real estate,
trust funds, stocks, stock options, bonds, other securities, commodities, etc.)
4. Your total assets. Add lines 1–3 ...................................................................................................... • 4 00

If your 2022 total assets on line 4 exceed $500,000, Stop here. You don’t qualify for the Property Tax Deferral Program.

Declaration
I declare under penalties for false swearing that I have examined all documents and to the best of my knowledge, they are true, correct,
and complete (ORS 305.990). I understand a lien will be placed on this property and I will be charged lien recording and/or security interest
fees. I understand that 6 percent interest accrues on each years’ deferred tax amount (ORS 311.666-701). I understand that heirs or other
transferees receiving the homestead following my death may be found liable for any unpaid debt accrued under the deferral program.
Applicant’s signature Date Joint applicant’s signature Date
X X

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                                                                                 17492301030000
Form OR-PTDA
                                     Oregon Department of Revenue
Page 3 of 3, 150-490-014  
(Rev. 07-25-22 ver. 01) 
                     County section (Don’t complete. This section will be completed by the county assessor’s office.)
Property      Platted
description • LOT ________________        BLK ________________   ________________________________________________ Legal description
(Please       Unplatted  For all unplatted properties attach a copy of the recorded deed or contract.
choose only 
one selection • Parcel in:  T ______________________      R ___________________________                           SEC_____________________________
as platted or 
unplatted.)   As described in _____________________________________________ County          Containing ________________________ acres

              Current deed     Deed recorded (date)    ________________________________________     
Deed          information                             •
                              Document/instrument number        Microfilm number                         Reel          Book/volume  Page
information
              Earliest deed showing       Recorded (date)                                                Document/instrument number
              ownership by the taxpayer(s)
                                          •
                            Assessor’s account number                                                    Levy code
                 Check  
              here for     •                                                                             •
              split levy    Assessor’s account number                                                    Levy code
              code
Assessor’s                 •                                                                             •
certification Property described above contains        If the property contains multiple units, what is the percentage  
                 Asingle unit        Multi-units       of value allocated to the taxpayer’s unit (percent to be deferred)?         •___________ %

                 Late filing         Fee paid
              Assessor’s (or Assessor’s designee’s) signature verifying applicant is the owner of record          Date              County number
              X

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