California Form 9000 - Homeowner Assistance Claim - 2002 Page 2
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1
2On line 8 through line 13 enter your total household income for the 2001 calendar year.
STEP D
See instructions on page 8 and page 9.
(Dollars)
(Cents)
Income of
household
8. Social Security and/or Railroad Retirement . . . . . . . . .
8.
members
9. Interest, Dividends, and/or Gain (or Loss) . . . . . . . . . .
9.
10. Pensions and/or Annuities . . . . . . . . . . . . . . . . . . . . . . .
10.
11. SSI/SSP, AB, and ATD (Gold Check). See page 8 . . . . . .
11.
(full year total)
12. Rental and Business Income (or Loss). See page 8 . . .
12.
13. Other Income (including wages). See page 9 . . . . . . . .
13.
14. SUBTOTAL. Add line 8 through line 13 . . . . . . . . . . . . . . .
14.
STEP E
Adjustments
15. Adjustments to Income. See page 10 . . . . . . . . . . . . . . .
15.
to income
STEP F
16. TOTAL HOUSEHOLD INCOME IN 2001.
Total
•
Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . .
16.
household
If line 16 is more than $37,119, stop. You do not qualify.
income
STEP G
•
.
17. PROPERTY TAX FOR 2001/2002 . . . . . . . . . . . . . . . .
17
Property tax
DO NOT INCLUDE SPECIAL OR DIRECT ASSESSMENTS.
paid and
Amount on line 17 cannot exceed 1% of the full value of the home.
homeowner
See page 10. You must attach a copy of your 2001/2002 property tax bill.
assistance
You do not have to complete line 18. If you stop here, we will figure the amount of
claimed
assistance for you.
18. Homeowner assistance claimed
(cannot exceed $472.60).
See page 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18.
Reminder
If this is your first year filing a Homeowner Assistance claim and you did not receive
SSI, please 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)
STEP H
Caution: To avoid delay of your check, be sure to provide all requested information, sign below, and
mail to: FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
Signature,
date, and
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information neces-
sary to process my claim, against information gathered from public records, the files of the Department of Health Services,
telephone
and other state or federal agencies to confirm my eligibility for the Homeowner 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.
‘ ‘ ‘ ‘ ‘
Sign Here
X___________________________________________________________ Date________________
Claimant’s signature
(
)
Claimant’s Daytime Telephone Number________________________________________
Date
Preparer’s social security number/PTIN
Paid
PREPARER’S
Check if
Preparer’s
SIGNATURE
self-employed
Use Only
FEIN/PTIN
FIRM’S NAME (OR YOURS, IF
SELF-EMPLOYED) AND ADDRESS
TELEPHONE (
)
Do not write in this space
Do not write in this space
L L L L L
D D D D D
I I I I I
A A A A A
R R R R R
RES
RES
RES
RES
RES
Side 2 FTB 9000 2002
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