Oregon Verification of Disabled Parent or Guardian for Oregon Working Family Child Care Credit

Verification of Disabled Parent or Guardian for Oregon Working Family Child Care Credit
Form WFC-DP, Verification of Disabled Parent or Guardian for Oregon Working Family Child Care Credit, 150-101-177
for Oregon Working Family Child Care
Clear Form
Oregon Form

WFC-DP

Verification of Disabled Parent or Guardian
for Oregon Working Family Child Care Credit

First name of disabled taxpayer

Last name of disabled taxpayer

For tax year

Social Security number (SSN) of disabled taxpayer

–	–
Important: The law was changed in 2007 to allow an exception if a spouse or registered domestic partner is disabled (ORS 315.262).
This exception is not available for tax year 2006 or earlier. This form is for tax years 2007 or later.
Instructions: Enter the name and SSN of the disabled taxpayer above. If the disability is not permanent, enter the tax year. If the disability is permanent and the physician identifies that the taxpayer will permanently meet the criteria listed below, enter “Permanent”
instead of the tax year. Your physician will need to complete Section B and keep a copy of this form signed by you, so that we may
verify the information provided.
Section A—To be completed by patient
I give permission for the physician and the physician’s employees to verify the existence and severity of my disability and other information on this form with the Oregon Department of Revenue. This authorization for this tax year expires four years from the date received
by the Oregon Department of Revenue.
Date

Signature of disabled taxpayer

X
Important:
•	 If your disability is not permanent, you will need to obtain a new verification form for each tax year you have a qualifying disability
for the working family child care credit.
•	 If your disability is permanent, you aren’t required to fill out this form each year that you claim this credit. When your physician has completed this form verifying that you have a permanent qualifying disability, keep the original form and include a copy with your return each
year that you claim the working family child care credit. Write “Permanent” in the tax year box at the top of this form.
•	 Include this form with your tax return. If you file your return electronically, fax this completed form to: (503) 345-2355, Attn: Suspense;
or mail it to: Oregon Department of Revenue, Attn: Suspense, PO Box 14999, Salem OR 97309-0990.
•	 To revoke this authorization to disclose, write “revoked” across this form and send a copy to both the physician and the Oregon
Department of Revenue.
•	 Keep this form with your records for at least four years after you file your tax return. We may ask you for a copy of this form during
that time.
Section B—To be completed by physician
I verify that the above person was unable to care for him or herself and had a disability that required assistance with one or more activities of daily living during the tax year indicated at the top of this form. This disability kept the person from doing all of the following:
•	 Providing child care;
•	 Being gainfully employed; and
•	 Attending school.
Check the activities of daily living that your patient required assistance with:
Dressing	

Feeding	

Toileting	

Other activity of daily living: _________________________________ .

Did your patient meet the criteria listed above for the entire tax year indicated at the top of this form?.......

Yes

No

If not, enter the dates during the year that your patient met the above criteria:	 ________________ 	to	________________
Do you expect your patient to continue to meet the criteria listed above for the foreseeable
future because the disability is permanent?....................................................................................................

Yes

Date

Physician’s signature

X
Please print or type:
Physician’s first name
Physician’s office address

Physician’s last name
Physician’s office phone

Note to physician: The Oregon Department of Revenue may contact you to verify this information.

—You must include this form with your Oregon income tax return—
150-101-177 (Rev. 10-15)

No