Tax And Rent Refund Application - Maine Revenue Services

*000372100*

6. Are you filing for the LOW-COST DRUG CARD? (See page 3 to see if you qualify) ................. 6.

Yes

7. ANNUAL HOUSEHOLD INCOME FOR 1999 (Total amount for Applicant, Spouse, and Dependents)

a. Maine adjusted gross income (from your 1999 Maine income tax return) .................................. 7a. $

Note: If you have not filed a 1999 Maine income tax return, leave this line blank and

enter your household income on line 7b.

b. Additional income (from schedule below) ................................................................................ 7b. $

c. Add line a and line b .................................................................................................................... 7c. $

d. Enter IRA, pension or annuity rollovers and Property Tax Program Refunds included on line 7a. .... 7d. $

(Read instructions on page 4 before entering an amount on this line.)

e. Total (subtract line 7d from line 7c) ............................................................................................. 7e. $

8. COSTS FOR PRESCRIPTION DRUGS. If line 7e is more than the income limits on page 3

for your household, enter money you paid for prescription drugs for all members of the

household in 1999. (See instructions on page 4.) ........................................................................... 8. $

9. Enter property tax assessed on your home in 1999 (See instructions on page 5) ...................... 9. $

(If your property tax bill is more than $1,500, attach the copy of the tax bill that has your name on it.)

a. Did you rent part of your home to others or use part of it for a business? ................................... 9a.

Yes

b. Was your home on a rented lot? ................................................................................................... 9b.

Yes

10. Enter total rent you paid on your home or lot in 1999 (Do not include mortgage payments) ..... 10. $

(If your rent is over $7,200, attach copies of your rent receipts.)

a. Does the rent on line 10 include heat? ......................................................................................... 10a.

Yes

b. Was your rent paid in part by the government? ............................................................................ 10b.

Yes

SCHEDULE OF ADDITIONAL INCOME

Column 1

Column 2

(for line 7b above)

For those who filed a

For those who did not

Additional Annual Income (Write in yearly income amounts.)

1999 Maine Income

file a 1999 Maine

Tax Return

Income Tax Return

a. Gross Salaries, Wages ................................................................. a.

a. $

b. Dividends, Interest - all sources ................................................. b.

b. $

c. Loss Add-Back .......................................................................... c. $

d. Social Security, Railroad Retirement, Pensions,

Annuities, Veterans Compensations ........................................... d. $

d. $

e. Cash Public Assistance, TANF (formerly AFDC) ...................... e. $

e. $

f. State Supplemental Income (This is not social

security income) ......................................................................... f. $

f. $

g. Any other Income ..................................................................... g. $

g. $

h. Total (add lines a through g) ....................................................... h. $

h. $

(Enter total from line h, either Column 1 or Column 2, on line 7b above.)

11. DIRECT DEPOSIT INFORMATION — If you want your refund sent directly to your bank account, see instructions on page 5 and fill in

the blocks below. NOTE: Completing the information below authorizes Maine Revenue Services to disclose your Social Security number, listed

on the front of this form, to your financial institution for the sole purpose of depositing your refund directly into your bank account.

11a. Routing

11b. Account

11c. Type of

Checking

Number:

Account:

Savings

Under penalty of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it is true, correct, and complete.

Applications may be audited either before or after refunds are issued. Refunds may be applied to other outstanding government debts you

may owe.

Date

Signature of Preparer other than Applicant

Date

Signature of Applicant

Mail your application in the envelope provided.

Office Use only: TB

Maine Revenue Services, PO Box 1069, Augusta, ME 04332-1069

Tax And Rent Refund Application - Maine Revenue Services - 2000 Page 2

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