Form Ar1000ptr - Homestead Property Tax Refund Claim - 2000
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12000
State of Arkansas
AR1000PTR
FOR 1999
REAL ESTATE
DO NOT STAPLE OR WRITE IN THIS AREA
Homestead Property Tax Refund Claim
REFUNDING 1999 REAL ESTATE TAXES PAID IN 2000
First Name and Initial (List both if applicable)
Last Name
Your Social Security Number
Present Address
Spouse’s Social Security Number
Date of Birth
City, Town or Post Office Box, State and Zip Code
Marital Status:
Telephone Number
1.
Single (Or Widowed)
2.
Married
Answer “yes” ONLY if you were younger than 62 on December 31, 2000 AND meet the disability requirements on Page 2 of this form.
3. Were you disabled as defined by SSA during 2000?
Yes
4. Were you a disabled veteran during 2000?
Yes
5. Were you a resident of Arkansas during ALL OF 1999 AND 2000?
Yes
No
6. Did you own and occupy a homestead during the ENTIRE YEAR OF 1999?
Yes
No
7. Are you a World War One veteran or widow of such a veteran?
Yes
No
2000 HOUSEHOLD INCOME
Income of
Income of
IMPORTANT NOTICE
Claimant
Spouse
Claimants who have spouses confined to a nursing home do not have to report income assigned to the nursing home.
(If applicable)
Please list all of your 2000 household income below. Enter the amounts received for the year.
8. * Social Security payments of all types, including amount deducted for Medicare. (See SSA-1099 Form. block 3) ... 8
00
00
9. * Veteran’s Pensions and disability payments. ....................................................................................................... 9
00
00
10. * Railroad Retirement benefits. ........................................................................................................................... 10
00
00
11.
Salaries, or income from Farm or self-employment: Remit schedule or statement. .............................................. 11
00
00
12.
Interest income from banks, saving and loan companies, etc. ........................................................................... 12
00
00
13.
Dividend income from banks, saving and loan companies, etc. .......................................................................... 13
00
00
14.
Rent and royalties income. (Submit Federal schedule or statement) ................................................................... 14
00
00
15.
Sales of real estate, stocks, bonds. (Submit Federal schedule or statement) ...................................................... 15
00
00
16. * Public employees retirement or Federal retirement and pensions. ...................................................................... 16
00
00
17.
Cash, Public Assistance and Relief (SSI, etc.) .................................................................................................. 17
00
00
18.
Miscellaneous income (Alimony payments, Workers’ Compensation, Loss of Time insurance,
or any other pension or annuity not listed above. Please list source.) ................................................................. 18
00
00
*These sources of income are not reportable for WWI veterans or widows of WWI veterans.
Total of Both Incomes
19.
Total 2000 income of claimant and spouse.
(If your total 2000 household income exceeds $30,000.00, you are not eligible to file this claim.) ...................................................
19
00
20.
From the table below, enter the maximum refund for the income on line 19. $ _______________________
21.
Enter your 1999 real estate taxes paid. (Please do not include personal property, improvement,
drainage sewage, or any special taxes which are not refundable. Attach 1999 receipt to claim.) ...................................................
21
00
Enter the SMALLER of Lines 20 or 21. This is the amount of your PTR Refund. ............................................................
22.
22
00
IF YOUR INCOME IS:
THE MAXIMUM REFUND IS:
IF YOUR INCOME IS:
THE MAXIMUM REFUND IS:
$0
to
$10,000 .................... for this income level
$325.00
$20,001
to
$25,000 .................... for this income level
$125.00
$10,001
to
$15,000 .................... for this income level
$225.00
$25,001
to
$30,000 .................... for this income level
$100.00
$15,001
to
$20,000 .................... for this income level
$175.00
I declare under the penalties of perjury that to the best of my knowledge this is a true, correct and complete claim. If prepared by another person,
this declaration is based on all the information of which he/she has knowledge. All information is subject to verification.
Claimant Signature
Date
Name, Address and Telephone Number of Agent or Preparer Other Than Claimant.
ID/SSN: ______________________________________________
Spouse’s Signature (If married, spouse must also sign)
Date
Name: _______________________________________________
Address: ______________________________________________
If signed by other than claimant, sign claimant’s name and give reasons for claimant’s
City: ____________________________ State: ___ Zip: ________
inability to sign, such as blind, disabled, etc. Also furnish information requested for agent
Telephone Number:( ________ ) ___________________________
or preparer.
PTR 1 (R 09/00)
Page 1
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