Form Sfn 24777 - Application For Senior Citizen Or Permanently And Totally Disabled Renter'S Property Tax Refund - 2011 Page 2
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1
2Application For Senior Citizen Or Permanently And
Totally Disabled Renter’s Property Tax Refund For The Year 2011
Any person 65 years of age or older with an income of $26,000 or less per year from all sources, including the income of
any person dependent upon him or her, may qualify for a renter’s property tax refund up to a maximum of $400.
Any person, regardless of age, who is permanently and totally disabled, with an income of $26,000 or less per year, may
also qualify for a renter’s refund. A physician’s certifi cate or written determination of disability from the Social Security
Administration must accompany only the fi rst application.
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Instructions For Numbered Lines On Front Of Application
Line 2: The estimated cost of services or items provided by the landlord such as utilities, furniture, or appliances, must
be entered on this line.
a.
b.
c.
d.
e.
Water &
Furniture &
Heat
Garbage
Lights
Appliances
Total
Check if provided by landlord
[ ]
[ ]
[ ]
[ ]
(Enter total on Line 2)
Cost of utilities, furniture and
appliances provided by landlord.
________
________
________
________
__________
Estimate the cost of the utilities provided by the landlord by multiplying the rent paid (amount on line 1) by the following
percentages: 14 percent for heat, 2 percent for water and garbage, and 6 percent for lights. The amount to report for
furniture and appliances ranges from approximately $15 per month for used items in an effi ciency apartment to $100 per
month for new items in a two bedroom apartment. Make no entry for furniture and appliances if only stove and refrigerator
are furnished. If the applicant has an unfurnished apartment and pays for all the utilities, enter “none” on line 2.
Lines 4-9: Income from all sources includes the income of a husband and wife, if they are living together, and any other
person dependent upon the applicant. This income from all sources includes, but is not limited to, social security benefi ts,
pensions, salaries, dividends, interest, net gains from the sale of property, net rental income, net profi t from any business,
including ranching and farming, and unemployment compensation. Life insurance death proceeds, Workers’ Compensation,
and Veterans’ Disability are not included as income.
Line 10: Medical expenses actually paid during the year for applicant and spouse/dependent are deductible from
income if not compensated by insurance or other payments. Use the following to compute the amount of medical expenses
allowable on line 10:
a. Total amount of health and hospital insurance premiums
(exclude Medicare) .................................................................................................... $ ________________________
b. Medicine and drugs (prescription only) .....................................................................
________________________
c. Doctor and dentist ......................................................................................................
________________________
d. Hospital costs .............................................................................................................
________________________
e. Hearing aids, eyeglasses, dentures, etc. .....................................................................
________________________
f. Home nursing care costs ............................................................................................
________________________
g. Nursing home care costs ............................................................................................
________________________
h. Transportation costs for medical care; 51 cents per mile for motor vehicle
effective 1/01/2011 ....................................................................................................
________________________
i. Total deductible medical expenses (total of lines a through h). Enter this amount
on line 10 on front of application .............................................................................. $
Confi dentiality. Income and medical expenses contained in this application are confi dential. However, they may be
disclosed to the board of county commissioners and county auditor, as needed, to carry out their offi cial duties.
In compliance with the Federal Privacy Act of 1974, Public Law 93-579, the disclosure of the individual’s social security number on this form is
mandatory pursuant to North Dakota Century Code § 57-02-08.1. An individual’s social security number is used as an identifi cation number
by the Offi ce of State Tax Commissioner for fi le control purposes and record keeping.
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