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Free Oregon Statement Form

The Oregon Statement form, also known as Form OR-SFC, is a financial statement that individuals must complete to provide a comprehensive overview of their financial condition. This form is essential for those facing collection actions, as it helps assess their financial situation and may lead to suspended collection status or modifications in wage garnishment. To ensure your form is processed without delay, make sure to fill out all sections accurately and completely.

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Content Overview

The Oregon Statement Form, also known as Form OR-SFC, is a crucial document for individuals seeking to provide a comprehensive overview of their financial situation. This form is designed to collect detailed information about personal and household income, assets, and liabilities. It includes sections for personal information, employment details, and a thorough financial analysis. Applicants must complete all sections to avoid delays in processing, which could lead to continued collection activities. Essential documents such as three months of bank statements, pay stubs, and profit and loss statements for businesses must accompany the form. Additionally, it allows individuals to apply for suspended collection status or modifications to wage garnishments. Completing the Oregon Statement Form accurately is vital, as it can significantly impact financial negotiations and potential relief options.

Similar forms

The Oregon Statement form is essential for providing a comprehensive overview of an individual's financial condition. It serves a specific purpose but has similarities with several other important documents. Here are four documents that share similarities with the Oregon Statement form:

Financial Disclosure Statement: Like the Oregon Statement, this document requires individuals to provide detailed information about their income, expenses, assets, and liabilities. Both forms aim to present a clear picture of financial health, often used in legal or financial proceedings.
Bankruptcy Petition: A bankruptcy petition includes a thorough account of an individual's financial situation, much like the Oregon Statement. Both documents necessitate listing assets, debts, and income sources to help determine the best course of action for financial relief.
Loan Application: When applying for a loan, applicants must disclose their financial condition, including income and outstanding debts. The level of detail required in both the loan application and the Oregon Statement ensures lenders can assess the applicant's ability to repay the loan.
Vehicle Purchase Agreement: Essential for those buying or selling a vehicle in California, this legally binding document includes crucial terms of sale and can be accessed for more details at legalpdf.org.
Tax Return: A tax return provides a detailed account of an individual's income and expenses over the year. Similarly, the Oregon Statement requires a snapshot of current financial conditions, including income sources and liabilities, making both documents crucial for understanding financial standing.

Preview - Oregon Statement Form

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

Last name

Your Social Security number

– –

Your date of birth

Other names or aliases used

Spouse/RDP’s irst

Last name

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.

State

(

)

(

)

Your email

Spouse/RDP’s email

Dependent’s name (living with you)

Date of birth

Social Security number

Relationship

–

Dependent’s name (living with you)

Date of birth

Social Security number

Relationship

–

Dependent’s name (living with you)

Date of birth

Social Security number

Relationship

–

Your current physical address

City

State

ZIP code

County

Your home phone

()

Your mailing address (if different from above)		City		State	ZIP code

Name of your tax representative (CPA, attorney, enrolled agent)	Fax number			Phone
	(		)	(	)

Address of your tax representative

City

State

ZIP code

Section 2. Employment information (personal and business)

Your employer or business name

Business phone

Payroll fax

	(	)	(		)
Address	City			State	ZIP code

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

Business phone

Payroll fax

	(	)	(		)

Address	City			State	ZIP code

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:____________________

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

					1	2	3	4

					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

Address

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.

Name of institution

Address

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) ........................

150-101-159 (Rev. 01-17)

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.

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 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	Type

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.

Type

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

Type

(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

Type

(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: ___________________________

C. Physical address

Type

(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: ___________________________

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 3

Section 3. (continued) General inancial information (personal and business)

D. Physical address

Type

(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: ___________________________

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	No	Yes _______________________________________________________________________________
Anticipated increase in income	No	Yes _______________________________________________________________________________
Bankruptcies/receiverships	No	Yes _______________________________________________________________________________
Recent transfer of assets	No	Yes _______________________________________________________________________________
Beneiciary to trust, estate, proit sharing, etc. ...	No	Yes _______________________________________________________________________________
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

150-101-159 (Rev. 01-17)

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	Totals
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

150-101-159 (Rev. 01-17)

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				Totals
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?			No	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)

150-101-159 (Rev. 01-17)

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.)

Amount

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.

Amount

71. Materials purchased (specify)

72.	Supplies (specify)

73. Installment payments (specify)

74.	Monthly payments (specify)

75. Rent / mortgage

If renting—name, address, and phone number of landlord

76.	Insurance

77. Business utilities: Electric: (		)

	Natural gas / oil: (	)	Phone, internet, & cable: (	)

	Garbage: (	)	Water / sewer: (	)

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.

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 7

Section 6. (continued) Additional information

Please provide any additional information not already included. Attach additional pages as needed. All household income must be included.

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

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

150-101-159 (Rev. 01-17)

Form OR-SFC, Financial Statement—Page 8

Key takeaways

Filling out the Oregon Statement form requires careful attention to detail. Here are key takeaways to keep in mind:

Complete All Sections: Ensure every section of the form is filled out. Incomplete forms cannot be processed, leading to potential collection activities.
Documentation Required: Attach three months of current bank statements, pay stubs, and profit and loss statements for businesses.
Household Income: Report all household income accurately. Use additional sheets if necessary.
Suspended Collection Status: Check the box if applying for suspended collection status. Review qualifications on the Oregon Department of Revenue website.
Wage Garnishment Modification: Indicate if you are applying for a modification regarding wage garnishment.
Personal Information: Provide accurate personal details, including Social Security numbers and contact information for yourself and your spouse or registered domestic partner (RDP).
Employment Information: List your employment details and those of your spouse/RDP, including occupation and pay frequency.
General Financial Information: Include details about bank accounts, vehicles, personal property, and life insurance. Attach supporting documentation as needed.
Assets and Liabilities: Clearly outline all assets and liabilities in the designated sections. Ensure calculations are accurate.
Review and Submit: Before submitting, double-check all information for accuracy. Errors can delay processing and lead to further complications.

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File Details

Fact Name	Details
Purpose of the Form	The Oregon Statement of Financial Condition (Form OR-SFC) is used to provide a comprehensive overview of an individual's financial situation.
Governing Law	This form is governed by the Oregon Revised Statutes, specifically ORS 305.265.
Required Sections	All sections of the form must be completed. Incomplete forms will not be processed, which can lead to further collection activities.
Supporting Documents	Applicants must submit three months of bank statements, pay stubs, and profit and loss statements if applicable.
Household Income	All household income must be reported, ensuring a complete financial picture.
Suspended Collection Status	Applicants can check a box to apply for suspended collection status, which may provide temporary relief from collections.
Wage Garnishment Modification	The form allows individuals to apply for modifications to wage garnishments, if necessary.
Personal Information Section	This section collects essential personal data, including names, Social Security numbers, and contact information.
Employment Information	Details about the applicant's employment and that of their spouse or partner are required, including employer names and contact information.
Asset and Liability Analysis	The form includes a section for analyzing assets and liabilities, helping to clarify financial standing.

Documents used along the form

The Oregon Statement form, also known as Form OR-SFC, is an essential document for individuals seeking to provide a comprehensive overview of their financial condition. This form is particularly important for those facing collection activities, as it helps in assessing eligibility for suspended collection status or modifications to wage garnishments. In conjunction with the Oregon Statement, several other documents may be necessary to provide a complete financial picture. Below is a list of these forms and documents, each described briefly.

Oregon Income Tax Return: This document is crucial for reporting an individual's income and tax obligations to the state. It provides a detailed account of earnings, deductions, and credits that may affect overall financial standing.
Wage Garnishment Modification Request: This request form is used to seek adjustments to existing wage garnishments. It allows individuals to present their current financial situation and argue for a more manageable repayment plan.
Non-disclosure Agreement: Protect sensitive information shared throughout the process by utilizing a Non-disclosure Agreement form available at Forms Georgia.
Proof of Income Documentation: This includes recent pay stubs, bank statements, or other financial records that demonstrate an individual's income. These documents are vital for verifying income levels when completing the Oregon Statement form.
Asset Verification Documentation: This encompasses various forms of proof for assets such as property deeds, vehicle titles, and bank statements. These documents help establish the total value of an individual's assets, which is necessary for the financial analysis required in the Oregon Statement.
Expense Documentation: This includes records of monthly expenses such as bills, loan payments, and living costs. Providing a clear picture of expenses is essential for assessing financial capacity and determining eligibility for financial relief options.

Each of these documents plays a critical role in the financial assessment process. Together with the Oregon Statement form, they provide a holistic view of an individual's financial situation, enabling appropriate actions to be taken in response to collection activities or other financial challenges.