Fillable California Form 9000 - Homeowner Assistance Claim

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On line 8 through line 13 enter your total household income for the 2002 calendar year.

STEP D

See instructions on page 10 and page 11.

(Dollars)

(Cents)

Yearly income

of household

8. Social Security and/or Railroad Retirement . . . . . . . . .

members

9. Interest, Dividends, and/or Gain (or Loss) . . . . . . . . . .

10. Pensions, Annuities and IRA distributions . . . . . . . . . .

10.

11. SSI/SSP, AB, and ATD (Gold Check). See page 10 . . . . .

11.

(full year total)

12. Rental and Business Income (or Loss). See page 10 . .

12.

13. Other Income (including wages). See page 11 . . . . . . .

13.

14. SUBTOTAL. Add line 8 through line 13 . . . . . . . . . . . . . . .

14.

STEP E

Adjustments

15. Adjustments to Income. See page 11 and page 12 . . . .

15.

to income

STEP F

16. TOTAL HOUSEHOLD INCOME IN 2002.

Total

•

Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . .

16.

household

If line 16 is more than $37,676, stop. You do not qualify.

income

STEP G

•

17. PROPERTY TAX FOR 2002/2003 . . . . . . . . . . . . . . . .

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 12. You must attach a copy of your 2002/2003 property tax bill.

assistance

claimed

You do not have to complete line 18. If you stop here, we will figure the amount of

assistance for you.

18. Homeowner assistance claimed

(cannot exceed $472.60).

See page 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

Side 2 FTB 9000 2003

California Form 9000 - Homeowner Assistance Claim - 2003 Page 2

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