Application For Property Tax Reduction For 2004 - Idaho State Commission Page 2
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2APPLICATION FOR PROPERTY TAX REDUCTION FOR 2004
ALL OF THE FOLLOWING QUESTIONS MUST BE COMPLETED. ATTACH SUPPORTING DOCUMENTS.
County
Code Area
Parcel Number
A.
B.
1. Ownership Information (Name, Address and Zip Code)
As of January 1, 2004, I was (check all that apply)
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65 or older
Blind
Former P.O.W.
Fatherless or Motherless Minor
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Widow(er): Spouse Name___________________ Date of Death________________
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Veteran 10-30% Service-connected disability
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Veteran 40-100% Service-connected disability
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Veteran Nonservice-connected disability with pension
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Recognized disabled:
Soc. Sec. Adm.
Fed. Civil Svc.
R/R Retirement
C.
2. Social Security Number (Claimant)
Social Security Number (Spouse)
Household Income and Qualified Expenses
January 1 - December 31, 2003
3. Birth Date (Claimant)
Birth Date (Spouse)
1. Federal Adjusted Gross Income .................... $ ____________________
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Extension filed
4. Telephone Number
2. Social Security Income (Claimant) ................ $ ____________________
3. Social Security Income (Spouse) .................. $ ____________________
5. As of January 1, 2004, I was (check only if applicable)
4. S.S.I. (Claimant) ............................................ $ ____________________
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Married
Widow(er)/Not remarried
5. S.S.I. (Spouse) .............................................. $ ____________________
6. Physical address of the property if different than Block 1
6. Pensions, Retirements, Annuities, and
IRA’s not included on line 1............................ $ ____________________
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7. Are you a new applicant?
Yes
No
7. VA Pension or Compensation ........................ $ ____________________
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8. Interest (Bank, Escrow, Dividends, etc)
8. Did you receive a Property Tax Reduction in 2003?
Yes
No
Taxable and Nontaxable not included
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on line 1 ........................................................ $ ____________________
9. If you live in a mobile home, do you own the land?
Yes
No
9. Railroad Retirement not included on line 1 .. $ ____________________
10. Have you filed a claim on a different primary residence
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10. Other income not included on line 1
between January 1, 2004 and now?
Yes
No
(Received from ..............................................) $ ____________________
11. Did you occupy your home as your primary residence
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11. Subtotal (add lines 1 through 10) .................. $ ____________________
before April 15, 2004?
Yes
No
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12. Capital Gains only if included on line 1 .......... $ (___________________)
12. Did you or your spouse stay in a care facility in 2003?
Yes
No
13. Total of non-reimbursed paid medical expenses
13. Do you receive rental income for all or any part of this property?
and medical insurance premiums .................. $ (___________________)
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(If yes, please attach a copy of your rental agreement.)
Yes
No
14. Total of paid or prepaid funeral expenses
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14. Is any portion of this property used for commercial use?
Yes
No
...... $ (___________________)
(Attach receipt - amount cannot exceed $5,000.)
15. Total Net Income ............................................ $ ____________________
15. This year will you or your spouse file:
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Federal Income Tax Return (If yes, please attach a copy.
Yes
No
D.
FOR COUNTY USE ONLY
If your tax information is incomplete, please contact your
county assessor for instructions on completing this form.)
Verification of Partial Ownership:
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I __________________________________________________________
State Income Tax Return (Which State?_______________)
Yes
No
County Assessor or Deputy Assessor
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certify that___________________________________________________
Idaho Grocery Credit Form _________________________
Yes
No
Name of Claimant
is a partial owner (excluding community interest) with ________% ownership
16. I grant permission to any government agency and contractor to confirm my
in this property and the Property Tax Reduction benefits only apply to the
status and to reveal to the Idaho State Tax Commission the total monetary
claimant’s portion of the net taxable value.
payments made to me or my spouse during 2003.
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1. Approved and verified by Assessor
2. Date:
(Check one)
Yes
No
or Deputy Assessor:
3. Tax reduction not to exceed:
Under penalty of perjury, I certify that to the best of my knowledge
the information I have provided here is true, correct, and complete.
The following section should be completed if the claimant is receiving
benefits on a prorated taxable value:
Claimant(s)
Date
4. Land taxable value (one acre or less)
$
____________________
5. Improvement(s) full value (one residence)
$
____________________
Signature(s) and Relationship
Telephone Number
6. Homeowner’s exemption
$ (___________________)
7. Net taxable (lines (4+5) – 6)
$
____________________
THIS COPY IS YOUR RECEIPT
WHITE-TAX COMMISSION
YELLOW - ASSESSOR
PINK - CLAIMANT
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