Form K-40pt - Kansas Property Tax Relief Claim For Low Income Seniors - 2011
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1
22011
K-40PT
135311
KANSAS PROPERTY TAX RELIEF CLAIM
(Rev. 7/11)
DO NOT STAPLE
for Low Income Seniors
FILE THIS CLAIM AFTER DECEMBER 31, 2011, BUT NO LATER THAN APRIL 15, 2012
- -
-
First four letters of
Claimant's
Claimant's
claimant's last name.
Social Security
Telephone
Number
Use ALL CAPITAL letters.
Number
First Name of Claimant
Last Name
Initial
Mark this box if claimant is
deceased (See instructions) . . . . .
Date of Death _____/_____/_____
Home Address (number and street or rural route)
IMPORTANT: Mark this box if
name or address has changed . . .
City
State
County Abbreviation
Zip Code
Mark this box if this is an
amended claim . . . . . . . . . . . . . . .
To qualify for this property tax refund you must meet the household income
NOTE: If you filed a Form K-40H
limitation and you must have been:
for 2011, you DO NOTqualify for
this property tax refund.
1. A resident of Kansas during the entire year of 2011;
MONTH
DAY
YEAR
2. A home owner during 2011; and,
3. Age 65 or over for the entire year. Enter your date of birth (must be prior to 1946) . . . . . . . . . .
Enter the total received in 2011 for each type of income. See instructions on the back of this form.
4. 2011 Wages OR Kansas Adjusted Gross Income $ _______________ plus Federal Earned Income Credit
,
.
00
$ _____________. Enter the total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. All taxable income other than wages and pensions not included in Line 4. Do not subtract net operating
.
,
00
losses and capital losses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
,
.
6. Total Social Security and SSI benefits, including Medicare deductions, received in 2011 (do not include
00
disability payments from Social Security or SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
,
7. Railroad Retirement benefits and all other pensions, annuities, and veterans benefits (do not include
00
disability payments from Veterans and Railroad Retirement). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
,
.
00
8. TAF payments, general assistance, worker's compensation, grants and scholarships . . . . . . . . . . . . . . . . . .
,
.
00
9. All other income, including the income of others who resided with you at any time during 2011. . . . . . . . . . .
,
.
00
. TOTAL HOUSEHOLD INCOME.
10
Add lines 4 through 9. If line 11 is more than $17,700, you do not qualify for a refund.
.
,
00
11.
General property taxes paid timely in 2011 (see instructions on the back of this form). . . . . . . . . . . . . . . . . . . . . .
,
.
00
. . . . .
12. PROPERTY TAX REFUND.
. . . . .
Multiply the amount on line 11 by 75% (.75). This is the amount of your refund.
Important:
If you filed Form ELG with your county, your refund will be reduced by the ELG amount applied to the first
half of your 2011 property tax.
Mark this box if you wish to participate in the Refund Advancement Program (see instructions)
. . . . . . . . . . . . . . . . . . . . . . .
I authorize the Director of Taxation or the Director's designee to discuss my K-40PT and any enclosures with my preparer.
I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, correct and complete claim.
_______________________________________
_____________
____________________________________
_______________________
Claimant's signature
Date
Signature of preparer other than claimant
Preparer's phone number
IMPORTANT: Please allow 20 to 24 weeks to process your refund.
PLEASE COMPLETE THE BACK OF THIS FORM
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