Form Hpc - 2005 Application For Homestead Preservation Credit - Missouri Department Of Revenue

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APPLICATION MUST BE

MISSOURI DEPARTMENT OF REVENUE

FORM

POSTMARKED BETWEEN

DIVISION OF TAXATION AND COLLECTION

HPC

2005 APPLICATION FOR HOMESTEAD

APRIL 1 AND

(REV. 12-2004)

SEPTEMBER 30, 2005.

PRESERVATION CREDIT

LAST NAME

FIRST NAME

INITIAL

BIRTHDATE (MM/DD/YY)

AGE

SOCIAL SECURITY NO.

–

SPOUSE’S LAST NAME

FIRST NAME

INITIAL

BIRTHDATE (MM/DD/YY)

AGE

SOCIAL SECURITY NO.

–

100% DISABLED:

YOURSELF

SPOUSE

MAILING ADDRESS

TELEPHONE NUMBER

CITY, STATE, ZIP CODE

1. If claiming credit eligibility due to being disabled, verification of disability is required. Attach a copy of approved forms of documentation (see

instructions) FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN CREDIT BEING DISALLOWED.

2. FEDERAL ADJUSTED GROSS INCOME AS SHOWN ON YOUR

2004 INDIVIDUAL INCOME TAX RETURN

(If you have not filed a 2004 Missouri return, you must attach a copy

(MUST BE $70,000 OR BELOW)

of your federal return.)

3. ADDRESS OF HOMESTEAD PROPERTY (primary residence owned and occupied) FOR WHICH APPLICATION IS FILED:

STREET ADDRESS

CITY, STATE, ZIP

4. I did not make improvements during 2004 that total more than 5 percent of the homestead value.

(If improvements total more than 5 percent of the homestead value, STOP. You do not qualify for the Homestead Exemption Credit.)

5. Attach copies of PAID real estate property tax receipts for 2003 and 2004 and/or PAID personal property tax receipts if homestead property is