Form 54-036a - Iowa Special Assessment Credit Claim - 1998
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11998
IOWA SPECIAL ASSESSMENT CREDIT CLAIM
To Be Filed in 1999
First Name
Claimant's Last Name
Claimant's Social Security Number
Claimant's Birth Date
County
Number
Spouse's Last Name
First Name
Spouse's Social Security Number
Month Day Year
Street Address
City, State, Zip Code
Do not write in this space
1. Were you totally disabled and 18 or older as of December 31, 1998 and presently disabled?..............
Yes
No
If yes, you must provide proof of your disability from your doctor or social security
office describing your disability and the date it began.
“Household income” includes the income of the claimant, the claimant’s spouse and
monetary contributions received from other persons living with the claimant.
Use Whole DOLLARS Only
1998 Household Income
0 0
2. Wages, salaries, tips, etc.
0 0
3. In-kind assistance for housing expenses
0 0
4. Title 19 Benefits (excluding medical benefits)
0 0
5. Social Security income
0 0
6. Disability income
0 0
7. All pensions and annuities
0 0
8. Interest and dividend income
9. Profit from business and/or farming and capital gains
If less than zero enter 0 (see instructions)
0 0
10. Money received from others living with you (See instructions)
0 0
11. Other income (Read instructions before making this entry)
0 0
12. Total lines 2 through 11
0 0
13. Medical and Care Expenses (See instructions on back)
0 0
14. SUBTRACT line 13 from line 12, enter here
0 0
(If more than $8,500. No Credit is Allowed)
This is your total household income
For Use by
Do not enter an amount on line 13 unless you are totally disabled and
County Treasurer Only
incurred medical or care expenses resulting from your disability. List
Installment
the nature and amount of each expense included on line 13.
Number________________
Annual Special
Assessment
Payment________________
State
I declare under penalty of perjury that I have reviewed this claim and
Reimbursement__________
to the best of my knowledge and belief, it is true, correct and complete
(
)
Claimant's Signature
Date
Telephone Number
This Claim Must be Filed with Your County Treasurer by September 30, 1999
54-036a (8/98)
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