Schedule H Form - Homeowner And Rental Property Tax Credit - 2001 Page 2
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17. HOUSEHOLD GROSS INCOME
Whole Dollar Amounts Only
Include the total income of all members living in the household which you own or rent
Office Use
(2)
(1)
(3)
SOURCES OF INCOME OR LOSS
SPOUSE
CLAIMANT
ALL OTHERS
(a) Wages, salaries, tips, bonuses, commissions, fees
(b) Dividends and Interest
(c) D.C. Lottery winnings
(d) Business Income or Loss
(e) Taxable portion of pensions and annuities
(f) Capital Gain
(g) Alimony received
(h) Net Rental Income
(i)
Social Security and/or Railroad Retirement Benefits
(j)
Nontaxable portion of Pensions and Annuities or exclusions
(k) Unemployment Insurance and/or Worker's Compensation
(l)
Support money and/or Public Assistance Grants
(m) Interest on U.S. Obligations
(n) Disability income exclusion, Form D-2440
(o) Non-taxable portion of military compensation
(p) Fellowship and scholarship awards and grants
(q) Life insurance proceeds
(r) Veteran's pensions and Disability payments
(s) GI Bill benefits
(t) Income subject to Unincorporated Business Franchise Tax
(u) Cash distributions
(v) Other (specify)
17
TOTAL HOUSEHOLD GROSS INCOME
18. HOUSEHOLD GROSS INCOME SUMMARY
(a) Total income of claimant from Column (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(a)
.00
(b) Total income of spouse from Column (2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(b)
.00
(c) Total income of all others from Column (3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(c)
.00
(d) Total household gross income (add Lines 18 (a), (b) and (c)). Enter here and on Line 6, Section A or
.00
(d)
Line 12, Section B, whichever is applicable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19. LIST THE NAMES AND SOCIAL SECURITY NUMBERS OF ALL PERSONS WHOSE INCOME IS INCLUDED IN COLUMN 3 ABOVE
Name
Social Security Number
Name
Social Security Number
How to Determine Your Property Tax Credit Use the Property Tax Credit tables on pages 38-44 of the D-40 Individual Income Tax Booklet.
If you are blind or disabled, you must have the certification below completed for each year that you claim the Property Tax Credit.
Physician’s Certification of Blind or Disabled Claimant
I certify that the above-named taxpayer (check all appropriate boxes — see instructions below):
(i)
is blind
(ii)
his/her physical or mental impairment is expected to last continuously for twelve months or more.
(iii)
was physically or mentally impaired on January 1, 2001
Name of Physician
Physician's Address
Physician's Signature
License Number
Date
Instructions for Physician's Certification
A. Definition of Blind - Blind means central visual acuity does not exceed 20/200 in the better eye with correcting lenses, or visual acuity is greater than 20/200, but is
accompanied by a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees.
B. Definition of Disabled - Disabled means unable to engage in any gainful activity by reason of a medically determinable physical or mental impairment which can be
expected to last continuously for twelve months or more.
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