Report of Gross Annual Income - Oregon 2026

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The document is a report form from the State of Oregon's Workers' Compensation Division, requiring workers receiving permanent total disability benefits to submit a sworn statement of their gross annual income. It outlines the need for reporting both earned income and other sources of income, provides instructions for completion and notarization, and includes guidance on common questions related to income reporting.

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Click ‘Get Form’ to open the Report of Gross Annual Income in the editor.
Begin by entering the date of injury, insurer name, and insurer’s claim number at the top of the form.
In the 'EARNED INCOME' section, list all income received from wages, salaries, and self-employment from January 1 to December 31. Ensure you include the source of this income.
Next, move to the 'OTHER INCOME' section. Here, report any additional income such as workers’ compensation benefits or social security. If you don’t have annual amounts, enter your most recent monthly check amount.
After filling out all sections, sign and date the form. Remember that notarization is required before submission.
Make three copies of your completed form: keep one for your records and send two copies along with the original to the Workers’ Compensation Division.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Oregon tax out of state income?

If you take benefits from the state, you should pay tax to cover the cost of providing those benefits. If you receive few or no benefits from the state, you shouldnt be required to pay Oregon tax on income earned outside the state.

How to see gross annual income?

When you receive consistent payments each month, you can calculate your gross annual income by multiplying your monthly income by 12. Be sure you are using your gross income for the month and not your net income, as in before any deductions.

Where to get gross annual income?

An individuals gross income is the total amount earned before taxes or other deductions are taken out. An employees pay stub will usually state their gross pay as well as their take-home pay.

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