Form 104 Ptc - Colorado Property Tax/rent/heat Rebate Application - 2004
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1DEPARTMENTAL USE ONLY
FORM 104 PTC
(63)
2004 COLORADO PROPERTY
TAX/RENT/HEAT REBATE APPLICATION
The Department of Revenue will calculate and mail your rebate checks quarterly.
Check here if this application is being filed to correct a previously filed 2004 PTC application.
LAST NAME
FIRST NAME AND INITIAL
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DECEASED
MONTH DAY YEAR
Yourself
YES
Spouse, if married
YES
Your telephone number
Address
(
)
City
State
ZIP Code
Colorado Driver License/ID numbers
Check only the first box that applies to you. If none apply, do not fill out this form because you do not qualify for this rebate.
A
I (or my spouse) was at least 65 years of age on December 31, 2004.
B
I was a widow or widower at least 58 years of age on December 31, 2004.
C
I was totally disabled for all of 2004 and received payment of full benefits from Social Security, SSI or the
Department of Human Services based solely on such disability.
D
I was totally disabled for all of 2004 and received payment of full benefits from a bona fide public or private plan
or source based solely on such disability. You MUST attach proof of disability (see page 4).
Enter your total 2004 income including wages (do not enter only monthly amounts). If married, the total income for both
spouses must be reported.
(Enter "0" if premiums
1. Enter number of months you received Medicare during 2004 .................................
1
Months
were paid by Medicaid)
2. Social Security, SSI and/or A.N.D. benefits received in 2004 .................................
2
.00
3. Colorado Old Age Pension payments received in 2004 ..........................................
3
.00
4. Private or VA pension payments received in 2004 ..................................................
4
.00
5. Wages, salaries and tips ..........................................................................................
5
.00
6. Interest and dividends ..............................................................................................
6
.00
7. Other income, Explain ________________________________________ ............
7
.00
Enter your 2004 property tax, rent and heat expenses.
8. If you paid 2003 property tax in 2004, enter amount here .......................................
8
.00
9. If you paid rent in 2004, enter the total for the year here .........................................
9
.00
10. If you paid heat or fuel expenses in 2004, enter the total for the year here ............
10
.00
11. Are your meals included in your rent payments?
No,
Yes,
Only part of the year enter amt.$ ________ .00
OR
12. Did you pay rent for a property tax exempt unit?
No,
Yes,
Only part of the year enter amt.$ ________ .00
OR
13. Was your heat included in your rent payments?
No,
Yes,
Only part of the year enter amt.$ ________ .00
OR
Have your rebate directly deposited (See page 6)
Type:
Checking
Savings
Routing number
Account number
I declare under penalty of perjury in the second degree that to the best of my knowledge and belief the information herein is true,
correct and complete. Furthermore, I authorize the Department of Revenue to contact the appropriate agencies to verify any
information provided on this form and the agencies are hereby authorized to release such information to the Department of Revenue.
MAIL TO: COLORADO DEPARTMENT OF REVENUE
Your Signature
Date
DENVER CO 80261-0005
Prepared by
Spouse's Signature
Date
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Parent category: Financial