California Form 9000r - Renter Assistance Claim - 2004
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YEAR
CALIFORNIA FORM
Renter
2004
9000R
Assistance Claim
(for income received in 2003)
Your first name
Initial
Last name
STEP 1
Spouse’s first name
Last name
Initial
Name and
address
Apt. no.
PMB no.
Present home address — number and street, PO Box or rural route
State
ZIP Code
City, town, or post office
-
STEP 2
Your social security number
Spouse’s social security number
IMPORTANT:
-
Social security
-
-
-
Your social security number
number
is required.
STEP 3
•
1. Are you a United States citizen? Check “Yes” or “No” . .
1.
NO
YES
If you checked “Yes,’’ skip line 2 and go to line 3.
Filing
If you checked “No,’’ go to line 2.
•
status
2. Benefit Eligibility for Noncitizens . . . . . . . . . . . . . . . . . . . .
2a.
Alien Status Code
I f you are not a citizen of the United States, go to page 10. If you
have a qualifying alien status for the United States, enter your
•
Alien Registration
alien status code from the chart on page 10 on line 2a. Then
2b.
Number
enter your alien registration number on line 2b and your date
•
of entry into the United States on line 2c. (MM/DD/YYYY)
2c.
Date of Entry
3. Check the appropriate box if you were one of the following on
December 31, 2003:
•
A. 62 years or older (see Note on page 5, line 3a) . . . . . .
A
•
B. Under 62 and blind . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B
•
C. Under 62 and disabled (not blind) . . . . . . . . . . . . . . . .
C
•
4. Enter your date of birth (example: 0 5/ 2 1 / 1 9 3 8) . . . . .
4.
You must enter your date of birth
MM DD Y Y Y Y
Date of Birth
See instructions on page 5 to see if you must attach a proof document
to your claim. If you cannot check one of the boxes, STOP HERE. You do
not qualify to file for a Renter Assistance claim.
STEP 4
5. Enter the total number of months during 2003 that you
lived in a qualified rented residence in California.
•
________months
Rental
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
information
6. If the address where you lived during 2003 is different than the address you
entered in Step 1, or if the address in Step 1 is a post office box, enter your 2003
Complete
residence address. (If more than one rented residence attach a list.)
line 5
Street Address
City
through
line 7.
¼
_________________________________________________________________________________________
State and ZIP Code
¼
___________________________________________
/
/
/
/
________________
________________
RENTED FROM
TO
7. Enter the name, address, and telephone number of your landlord or the person
to whom you paid rent during 2003. (If more than one landlord attach a list.)
NAME ___________________________________________________________________________________________________________
ADDRESS ______________________________________________________________________________ APT. OR UNIT NO._________
_____________________
CITY _______________________________________________________ STATE and ZIP CODE_________
TELEPHONE (
) ____________________________________
For Privacy Act Notice, see Page 9.
FTB 9000R 2004 Side 1
Complete Side 2, Step 5 Through Step 9.
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