Form Sfn 27777 - Application For Senior Citizen Or Permanently And Totally Disabled Renter'S Property Tax Refund - 2007

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2007
Application For Senior Citizen Or Permanently And
Totally Disabled Renter’s Property Tax Refund
OFFICE OF STATE TAX COMMISSIONER
SFN 27777 (Rev. 9-06)
Name (If joint, use fi rst name and initials of both)
Applicant’s Social Security Number
Mailing Address
Spouse’s Social Security Number
City, State, Zip Code
Applicant’s Date Of Birth
Daytime Phone Number
Landlord’s Name
(
)
Please mail by May 31, 2008 to:
Mailing Address
Offi ce of State Tax Commissioner
600 E. Boulevard Ave., Dept. 127
City, State, Zip Code
Phone Number
Bismarck, ND 58505-0599
(
)
Certifi cation of Rent Paid in 2007
1. Amount of annual rent paid personally by applicant for 2007 ................................................................ $
2. Cost of utilities, furnishings, and all other services provided by the landlord
(enter Total from Line 2 instructions, Column e, on back of application) ............................................... $
3. Net rent paid (subtract line 2 from line 1) ................................................................................................ $
Total Income for Calendar Year 2007
4. Applicant’s and spouse’s income from Social Security benefi ts (exclude Medicare) .............................. $
5. Applicant’s and spouse’s income from salary and wages ........................................................................ $
6. Applicant’s and spouse’s income from interest ........................................................................................ $
7. Applicant’s and spouse’s income from other sources (S.S.I., net rental income, net income from
business, capital gains, unemployment compensation, etc.) .................................................................... $
8. Dependents’ income from all sources ...................................................................................................... $
9. Total income from all sources (add lines 4, 5, 6, 7 and 8) ..................................................................... $
10. Deductible medical expenses (see instructions for line 10 on back of application)................................. $
11. Total income less medical expenses (subtract line 10 from line 9) ........................................................ $
If the amount on line 11 exceeds $17,500, you are not eligible for the credit.
Refund Computation
If you want the Tax Department to compute your refund, it is not necessary for you to complete this section
12. Enter 20 percent of net rent paid (20 percent of line 3) ........................................................................... $
13. Enter 4 percent of total income less medical expenses (4% of line 11) ................................................... $
14. Amount of renter’s credit (subtract line 13 from line 12). If line 13 is larger than line 12,
you are not eligible for the credit ............................................................................................................. $
Refund Cannot Exceed $240
I declare under the penalties of N.D.C.C. § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental matter, that this return,
including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true, correct, and complete return.
________________________________________________________________________________________
________________________________________________
Signature of Applicant
Date
________________________________________________________________________________________
________________________________________________
Signature of Preparer if other than Applicant
Telephone No.
Date
24777

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