California Form 9000r - Renter Assistance Claim - 2007 Page 2
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STEP 5
On line 8 through line 13 below, enter your household income for the 2006 calendar year.
Include the income of your spouse and certain other household members. See instructions for
Yearly
other household members on page 7 and page 8.
income of
(Dollars)
(Cents)
household
members
8. Social Security and/or Railroad Retirement . . . . . . . . . . . . . . . . . 8.
9. Interest, Dividends, and/or Gain (or Loss) . . . . . . . . . . . . . . . . . . . 9.
10. Pensions, Annuities, and IRA distributions . . . . . . . . . . . . . . . . . . 10.
11. SSI/SSP, (gold Check). See page 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
(full-year total)
12. Rental and Business Income (or Loss) . . . . . . . . . . . . . . . . . . . . . . . 12.
See page 7 . Do not enter your monthly rent payments.
13. Other Income (including wages, spouses income). See page 7. 13.
14. Subtotal. Add line 8 through line 13 . (This is your
total yearly income before adjustments .) . . . . . . . . . . . . . . . . . . . . . 14.
15. Adjustments to Yearly Income. See page 8 . . . . . . . . . . . . . . . . . 15.
(If you do not have any adjustments to income, enter zero and go
to line 16 .)
16. TOTAL YEARLY HOUSEHOLD INCOME IN 2006.
•
16.
Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If line 16 is more than $42,770, STOP . You do not qualify.
Do you receive Temporary Assistance for Needy Families, formerly Aid
YES
NO
to Families with Dependent Children (AFDC)? . . . . . . . . . . . . . . . . . . . . .
STEP 6
You do not have to complete line 17. If you stop here, we will figure the amount of
assistance for you.
Renter
assistance
17. Renter assistance claimed. (Optional)
claimed
(Cannot exceed $347.50) See page 13 . . . . . . . . . . . . . . . . . . . . 17.
Reminder
If this is your first year filing a Renter Assistance claim and you did not receive SSI, provide proof of
your age, disability, or blindness .
If you filed a claim last year and are under 62 years old, you will need to provide proof of your temporary
disability if you did not receive SSI . (This is an annual requirement .)
Caution: To avoid delay of your check, be sure to provide all required information, sign below, and mail to:
STEP 7
FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
Signature,
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information necessary to
date, and
process my claim, against information gathered from public records, the files of the Department of Health Services, and other state or
telephone
federal agencies to confirm my eligibility for the Renter Assistance Program .
number
Under penalties of perjury, I declare that this claim and all statements regarding my eligibility and citizenship or alien status, including
accompanying schedules and any additional information I may provide to the Franchise Tax Board are to the best of my knowledge,
true, correct, and complete . By signing this claim, I authorize the Franchise Tax Board to mail any assistance to which I am entitled,
pursuant to this claim, to the address listed in step one .
Print Name __________________________________________________________________________
Sign Here
x_______________________________________________________________ Date________________
Claimant’s signature
•
( )
Claimant’s Daytime Telephone Number
________________________________________
Date
Check if
Preparer’s social security number/PTIN
PREPARER’S
self-employed
SIgNATURE
Paid
FEIN
Preparer’s
FIRM’S NAME (OR YOURS, IF
Use Only
SElF-EMPlOYED) AND ADDRESS
TElEPHONE (
)
Do not write in this space
Do not write in this space
L
D
I
A
R
RES
Side FTB 9000R 2007
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