Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2009

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Departmental Use Only

DR 104 PTC (11/25/09)

Vendor ID

COLORADO DEPARTMENT OF REVENUE

DENVER CO 80261-0005

2009 COLORADO PROPERTY

(1063)

TAX/RENT/HEAT REBATE APPLICATION

The Department of Revenue will calculate and mail your rebate checks quarterly.

Check here if this application is being filed to correct a previously filed 2009 PTC application.

LAST NAME

FIRST NAME AND INITIAL

DECEASED

DATE OF BIRTH

SOCIAL SECURITY NUMBER

Yourself

MONTH

DAY

YEAR

YES

Spouse, if married

YES

Physical address (Must match the address on record for your driver's license/ID card)

Your telephone number

Your email address

(

)

City

State

ZIP Code

Colorado driver's license/ID number

Expiration Date

Colorado driver's license/ID number

Expiration Date

If you did not live at the address listed above for all of 2009, you must attach a list of addresses at which

you lived during 2009 and the dates you lived at each location.

Check the first box that applies to you. If none apply, do not fill out this form because you do not qualify for this rebate.

I (or my spouse) was at least 65 years of age on December 31, 2009.

I was a widow or widower at least 58 years of age on December 31, 2009.

I was totally disabled for all of 2009 and received payment of full benefits from Social Security, SSI or the Department of Human

Services based solely on such disability.

I was totally disabled for all of 2009 and received payment of full benefits from a bona fide public or private plan or source based

solely on such disability. You MUST attach proof of disability (see page 5).

Enter your total 2009 income including wages (do not enter only monthly amounts). If married, the total income for both spouses must be reported.

(Enter "0" if premiums were paid by Medicaid)

1 Enter number of months you received Medicare during 2009 ....................................................................... 1

_______Months

.00

2 Social Security, SSI and/or A.N.D. benefits received in 2009 ........................................................................ 2

.00

3 Colorado Old Age Pension payments received in 2009. ............................................................................... 3

4 Private or VA pension payments received in 2009. ....................................................................................... 4

.00

5 Wages, salaries and tips ............................................................................................................................... 5

.00

6 Interest and dividends ................................................................................................................................... 6

.00

7 Other income, Explain ________________________________________ .................................................. 7

Enter your 2009 property tax, rent and heat expenses.

.00

8 If you paid 2008 property tax in 2009, enter amount here ............................................................................. 8

.00

9 If you paid rent in 2009, enter the total for the year here ............................................................................. 9

.00

10 If you paid heat or fuel expenses in 2009, enter the total for the year here ............................................... 10

.00

11 Are your meals included in your rent payments?

No,

Yes, OR

Only part of the year enter amt ... 11

.00

12 Did you pay rent for a property tax exempt unit?

No,

Yes, OR

Only part of the year enter amt .. 12

.00

13 Was your heat included in your rent payments?

No,

Yes, OR

Only part of the year enter amt ... 13

Have your rebate directly deposited (See page 7)

Type:

Savings

Checking

Routing number

Account number

I declare under penalty of perjury in the second degree that to the best of my knowledge and belief the information herein is true, correct and complete.

Furthermore, I authorize the Department of Revenue to contact the appropriate agencies to verify any information provided on this form and the

agencies are hereby authorized to release such information to the Department of Revenue.

Your Signature

Date

MAIL TO: Colorado Department of Revenue,

Denver, CO 80261-0005

Spouse Signature

Date

Prepared by

IMPORTANT—You must also complete and sign the affidavit on the back of this form.

104PTC Booklet Page 3