California Form 9000h - Homeowner Assistance Claim - 2006
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1
2YEAR
CALIFORNIA FORM
Homeowner
2006
Assistance Claim
9000H
(for income received in 2005)
Your first name
Last name
Initial
STEP 1
Spouse’s first name
Last name
Initial
Name and
address
Present home address — number and street, PO Box or rural route
Apt. no.
PMB no.
Place
label here,
State
ZIP Code
City, town, or post office
-
type, or print
STEP 2
IMPORTANT:
Your
Your
-
-
-
-
Social security
Your SSN
Spouse’s
SSN
is required.
number (SSN)
SSN
STEP 3
•
1. Are you a United States citizen? Check “Yes” or “No” . . . . .
1.
YES
NO
If you checked “Yes,’’ skip line 2 and go to line 3.
Filing
If you checked “No,’’ go to line 2.
status
•
2. Benefit Eligibility for Noncitizens . . . . . . . . . . . . . . . . . . . . . .
2a.
Alien Status Code
If you are not a citizen of the United States, go to page 10. If
•
you have a qualifying alien status for the United States, enter
2b.
Alien Registration
your alien status code from the chart on page 10 on line 2a.
Number
Then enter your alien registration number on line 2b and your
•
date of entry into the United States on line 2c. (MM/DD/YYYY)
2c.
Date of Entry
3. Check the appropriate box if you were one of the following on
December 31, 2005:
•
A. 62 years or older (See Note on page 5, line 3a) . . . . . . . .
A
•
B. Under 62 and blind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B
•
C. Under 62 and disabled (not blind) . . . . . . . . . . . . . . . . . .
C
If you cannot check one of the boxes, STOP HERE. You do not qualify to
file for a Homeowner Assistance claim.
•
4. Enter your date of birth (example: 0 5/ 2 1 / 1 9 4 3) . . . . . . . .
4.
MM D D
Y Y Y Y
You must enter your date of birth
Date of Birth
See instructions on page 5 to see if you must attach a proof document to
your claim.
STEP 4
5. Did you own and live in your home on
December 31, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
NO
YES
Property
If “No,” STOP. You do not qualify for homeowner assistance.
a. Enter the NET value of your property.
information
•
$
See page 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5a.
from
6. Is your property used for rental and/or business
2005/2006
as well as personal use? . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
NO
YES
tax bill
If you checked “Yes,” enter the estimated percentage of
%
property devoted to your personal use. See page 6 . . . . . . . . . .
6a.
7. List name(s) and relationship(s) of anyone, other than
yourself, who is included on your property tax bill.
See page 6.
Did this person live in
your home in 2005?
Name______________________ Relationship________________
YES
NO
Name______________________ Relationship________________
YES
NO
Name______________________ Relationship________________
YES
NO
%
Enter your percentage of ownership . . . . . . . . . . . . . . . . . . . .
7.
For Privacy Act Notice, see Page 9.
FTB 9000H 2006 Side 1
Complete Side 2, Step 5 Through Step 9.
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