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Income Calculation Worksheet - South Dakota Department Of Revenue & Regulation - 2007 Page 2

Household Information

OTHER HOUSEHOLD MEMBERS: If you live with others in a single household, you must include their income as well as your own.

If you are applying as part of a household, please list the other members here.

Last Name

First Name and Middle Initial

Relationship

Age

Social Security Number

Eligibility

Eligibility for a Property Tax Refund

Eligibility for a Sales Tax Refund

Yes

Have you owned the house you are now

Were you a South Dakota resident

living in for at least three years?

during all of 2006?

If you have owned your house for less

Were you 65 on or before January 1,

than three years, have you been a

2006, or disabled at any time during

resident of South Dakota for five

2006? Proof of disability is required

years or more?

each year.

If you answered “yes” to either of these two questions and

Do you live alone and have a yearly

answered “yes” to the sales tax questions on the left side

income under $10,000? OR

of this section, you may be eligible for a property tax

refund.. Please send a copy of the 2006 real estate

Do you live in a household whose

tax statement that you received from your county

members combined income is

treasurer.

under $13,000?

Property Tax Refunds for Widows and Widowers Under Age 65

Yes

Are you under age 65 and have

If you answered “yes, you may be

a deceased spouse who received

eligible for a property tax refund.

a property tax refund in the year

Please enter the date of your

preceding his/her death?

spouse’s death.

Month _____ Day _____

Signature

Year _____

I have examined this claim, and it is correct to the best of my knowledge. I authorize any other person holding official Social Security records, official

public aid records, official Veterans Administration records or any other records containing information relevant to this claim to disclose the information

contained on the records to the South Dakota Department of Revenue & Regulation.

Preparer’s Signature

Date

Address

City

Telephone Number

Claimant’s Signature

Date