Form Ar1000ptr - Homestead Property Tax Refund Claim - 1999

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1999
State of Arkansas
AR1000PTR
FOR 1998
DO NOT STAPLE OR WRITE IN THIS AREA
REAL ESTATE
Homestead Property Tax Refund Claim
REFUNDING 1998 REAL ESTATE TAXES PAID IN 1999
FIRST NAME and INITIAL (List both if applicable)
LAST NAME
YOUR SOCIAL SECURITY NUMBER
PRESENT ADDRESS (Number and Street, Apartment Number or Rural Route)
SPOUSE’S SOCIAL SECURITY NUMBER
CITY, TOWN OR POST OFFICE, STATE AND ZIP CODE
DATE OF BIRTH
:
0
MARITAL STATUS
TELEPHONE NUMBER
SINGLE (Or Widowed)
MARRIED
1.
2.
Answer yes only if you were younger than 62 on October 1, 1999 and meet the disability requirements on page 2 of this form.
Were you disabled and on MEDICAID during 1999?
YES
4. Were you a disabled veteran during 1999?
YES
03.
resident of Arkansas during ALL OF 1998 AND 1999?
YES
NO
6. Did you own and occupy a homestead during the ENTIRE YEAR OF 1998?
YES
NO
05. Were you a
?
YES
NO
7. Are you a World War One veteran, or the widow of such a veteran
1999 HOUSEHOLD INCOME
Income of
Income of Spouse,
Claimant
if applicable
IMPORTANT NOTICE
Claimants who have spouses confined to a nursing home do not have to report income assigned to the nursing home.
Please itemize all of your 1999 household income below. Enter the amounts received for the year.
8. * Social Security payments of all types, including amount deducted for Medicare. (See SSA-1099 Form. block 3). .................. 8
.00
.00
0
.00
.00
9. * Veteran’s Pensions and disability payments. ............................................................................................................................. 9
0
. * Railroad Retirement benefits. .................................................................................................................................................... 10
.00
.00
10
.00
.00
11.
Salaries, or income from Farm or self-employment: Remit schedule or statement. .................................................................. 11
12.
Interest income from banks, savings and loan companies, etc. ................................................................................................ 12
.00
.00
13.
Dividend income from banks, savings and loan companies, etc. .............................................................................................. 13
.00
.00
.00
.00
14.
Rent and royalties income. (Submit Federal schedule or statement). ........................................................................................ 14
15.
Sales of real estate, stocks, bonds. (Submit Federal schedule or statement). ........................................................................... 15
.00
.00
.00
.00
16. * Public employees retirement or Federal retirement and pensions. ............................................................................................. 16
17.
Cash, Public Assistance and Relief (SSI, etc.) .......................................................................................................................... 17
.00
.00
18.
Miscellaneous income (Alimony payments, Workers’ Compensation, Loss of Time insurance,
or any other pension or annuity not listed above. Please list source.) ....................................................................................... 18
.00
.00
* These sources of income are not reportable for WWI veterans or widows of WWI veterans.
19. Total 1999 Income of claimant and spouse.
Total of Both Incomes
(If your total 1999 household income exceeds $25,000.00, you are not eligible to file this claim.)........................................................................................ 19
.00
20. From the table below, enter the maximum refund for the income on Line 19. $ ____________________________________________________
21. Enter your 1998 real estate taxes paid. (Please do not include personal property, improvement , drainage sewage, or any
special taxes which are not refundable. Attach 1998 receipt to claim.)
21
.00
22. Enter the SMALLER of Lines 20 or 21. This is the amount of your PTR Refund. .......................................................................................................... 22
.00
IF YOUR INCOME IS:
THE MAXIMUM REFUND IS:
IF YOUR INCOME IS:
THE MAXIMUM REFUND IS:
$0
to
$08,000.00................................for this income level
$300.00
$10,001.00
to
$11,000.00................................for this income level
$150.00
$8,001.00
to
$09,000.00................................for this income level
$250.00
$11,001.00
to
$12,000.00................................for this income level
$125.00
$9,001.00
to
$10,000.00................................for this income level
$200.00
$12,001.00
to
$25,000.00................................for this income level
$100.00
I declare under the penalties of perjury that to the best of my knowledge this is a true, correct and complete claim.
If prepared by another person, this declaration is based on all the information of which he has knowledge. All information is subject to verification.
CLAIMANT SIGNATURE
DATE
NAME, ADDRESS AND TELEPHONE NUMBER OF AGENT OR PREPARER OTHER THAN THE CLAIMANT
SIGN
HERE
ID/SSN#
_____________________________________
SPOUSE’S SIGNATURE (If married, spouse must also sign).
DATE
Name: _________________________________________
SIGN
HERE
Address: ________________________________________
City: _________________State: ______Zip: _____________
If signed by other than claimant, sign claimant’s name, and give reasons for claimant’s inability to sign, such as
blind, disabled, etc. Also furnish information requested for agent or preparer.
Phone Number: (
) ___________________________
PTR 1 (R 11/99)
Page 1

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