Form 104 Ptc - Colorado Property Tax/rent/heat Rebate Application - 2008 Page 2
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2DR 4679 PTC (09/27/07)
COLORADO DEPARTMENT OF REVENUE
AFFIDAVIT - RESTRICTIONS ON PUBLIC BENEFITS
PRIMARY APPLICANT
I, ______________________________________________________________ , swear or affirm under penalty of
perjury under the laws of the State of Colorado that (check one):
1.
I am a United States citizen.
2.
I am not a United States citizen but I am a Permanent Resident of the United States.
3.
I am not a United States citizen but I am lawfully present in the United States
pursuant to Federal law.
If you are not a United States citizen, enter your Alien Registration Number.
A# ________________________________________________________
SPOUSE, IF MARRIED
I, ______________________________________________________________ , swear or affirm under penalty of
perjury under the laws of the State of Colorado that (check one):
1.
I am a United States citizen.
2.
I am not a United States citizen but I am a Permanent Resident of the United States.
3.
I am not a United States citizen but I am lawfully present in the United States
pursuant to Federal law.
If you are not a United States citizen, enter your Alien Registration Number.
A# ________________________________________________________
I understand that this sworn statement is required by law because I have applied for a public benefit. I understand
that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this
public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this
sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado
Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently
received.
Primary Applicant Signature
Date
Spouse Signature
Date
104PTC Booklet Page 4
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