Qualifying Checklist, Form 104 Ptc - Colorado Property Tax/rent/heat Rebate - 1998
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2QUALIFYING CHECKLIST
You must complete this side of the form first.
A. Age or Disability Status
Which of the following applies to you? If none apply, do not fill out or file this form because you do not qualify for this
rebate. If A or B apply, do not check C.
A
I (or my spouse) was at least 65 years of age on December 31, 1998
B
I was a widow or widower at least 58 years of age on December 31, 1998
C
I was totally disabled for all of 1998 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 if your benefits are paid by any
agency other than Social Security or SSI (see page 5).
Deceased Spouse's Name
Spouse's Social Security Number
Date of Death
B. Residency Status
Were you a Colorado resident for the entire year of 1998? (If married, both spouses must be residents.)
Yes
No
If no, you do not qualify for this rebate. Do not continue to fill out this form.
Do not send it to the Department of Revenue.
Have you received this rebate in any previous year?
Yes
No
If no, you must attach a copy of your proof of residency.
First time applicants must provide proof of residency for the entire year of 1998. Examples of proof are:
• A copy of your 1998 lease.
• A valid Colorado Driver License or I.D. for all of 1998 (enter number below).
Your Colorado Driver License/I.D.#
Colorado Driver License/I.D.# of spouse or other person sharing residence
C. Payment of Property Tax/Rent/Heat Expenses
1. What were the 1997 property taxes you paid in 1998? $_____________
2. What were the total rent payments you paid for your house/apartment in 1998? $_____________
2a. Are your meals included in your rent payments ?
No
Yes If yes, enter only one-half of
the total rent payments on line 2 above.
2b. Did you pay rent for a property tax exempt unit?
No
Yes If yes, enter -0- on line 17.
2c. Was your heat included in your rent payments?
No
Yes If yes, enter 90% of your total
rent from line 2 above on line 17 (unless you answered yes to question 2b above), and enter
100% of your total rent from line 2 above on line 24.
2d. Were you a resident in a nursing home during 1998?
No
Yes If yes, see page 6 to see
if you qualify.
3. How much did you pay for your heat or fuel bills in 1998? $_____________
D. General Information
Are there other individuals residing in your household?
No
Yes If yes, give person's name(s) and Social Security no(s). below: (include children only if
they have income)
Name
Social Security Number
Name
Social Security Number
Name
Social Security Number
Were you on Medicare during 1998?
No
Yes, all year
Yes, but only _______ months
If yes, enter $526 on line 5 for premiums that were paid on your behalf. If you only received Medicare
benefits for part of the year, multiply the number of months you received benefits times $43.80 for the
amount of the premiums to include on line 5.
Statute of Limitation: A claim for the 1998 Property Tax/Rent/Heat Rebate will be accepted only if filed
on or before December 31, 2000.
PTC 104 Booklet Page 3
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