California Form Ftb 9000 - Homeowner Assistance Claim - 2000 Page 2
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1
2On line 8 through line 15 enter your total household income for the 1999 calendar year.
STEP D
If you are married, include your spouse’s income. On line 17, enter the total income of
1999 income
other household members.
(Dollars)
(Cents)
of you and
8. Social Security and/or Railroad Retirement . . . . . . . . .
your spouse
8.
9. Interest and/or Dividends . . . . . . . . . . . . . . . . . . . . . . . .
9.
10. Pensions and/or Annuities . . . . . . . . . . . . . . . . . . . . . . .
10.
11. SSI/SSP, AB, and ATD (Gold Check). See page 9 . . . . . .
11.
12. Rental Income (or Loss). See page 9 . . . . . . . . . . . . . . . .
12.
13. Business Income (or Loss). See page 9 (full year total)
13.
14. Gain (or Loss) from sale of assets. See page 10 . . . . .
14.
15. Other Income (including wages). See page 10 . . . . . . .
15.
16. SUBTOTAL. Add line 8 through line 15 . . . . . . . . . . . . . . .
16.
STEP E
17. Income of Other Household Members in 1999.
1999 Income of
See page 10. Do not include your income or the
other household
income of your spouse, minors, students, or renters . . . .
17.
members
STEP F
18. SUBTOTAL. Add line 16 and line 17 . . . . . . . . . . . . . . . . .
18.
1999 Total
19. Adjustments to Income. See page 11. . . . . . . . . . . . . . .
19.
household
20. TOTAL HOUSEHOLD INCOME IN 1999.
income
•
Subtract line 19 from line 18 . . . . . . . . . . . . . . . . . . . . . .
20.
If line 20 is more than $33,993, stop. You do not qualify.
STEP G
•
.
21. PROPERTY TAX FOR 1999/2000 . . . . . . . . . . . . . . . .
21
Property tax
DO NOT INCLUDE SPECIAL OR DIRECT ASSESSMENTS.
paid and
See page 11. Attach a copy of your 1999/2000 property tax bill.
homeowner
You do not have to complete line 22. If you stop here, we will figure the amount of
assistance
assistance for you.
claimed
22. Homeowner assistance claimed
(cannot exceed $326.40).
See page 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22.
STEP H
Caution: To avoid delay of your check, be sure to provide all requested information, sign below and
mail to: FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
Signature,
date, and
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information neces-
sary to process my claim, against information gathered from public records, the files of the Department of Health Services,
telephone
and other state or federal agencies to confirm my eligibility for the Homeowner Assistance Program.
number
Under penalties of perjury, I declare that this claim and all statements regarding my eligibility and citizenship or alien status,
including accompanying schedules and any additional information I may provide to the Franchise Tax Board are to the best
of my knowledge, true, correct, and complete.
‘ ‘ ‘ ‘ ‘
Sign Here
X___________________________________________________________ Date________________
Claimant’s signature
(
)
Claimant’s Daytime Telephone Number (optional)________________________________________
Date
Preparer’s social security number/PTIN
Paid
PREPARER’S
Check if
Preparer’s
SIGNATURE
self-employed
Use Only
FEIN
FIRM’S NAME (OR YOURS, IF
SELF-EMPLOYED) AND ADDRESS
TELEPHONE (
)
Do not write in this space
Do not write in this space
L L L L L
D D D D D
I I I I I
A A A A A
R R R R R
RES
RES
RES
RES
RES
Side 2 FTB 9000 2000
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