Form Mo-Ptc - Property Tax Credit Claim/ Pharmaceutical Tax Credit - 2000

Enclosure Sequence No. 1040-07

MISSOURI DEPARTMENT OF REVENUE

2000

DLN

PROPERTY TAX CREDIT CLAIM/

FORM

PHARMACEUTICAL TAX CREDIT

MO-PTC

YOUR LAST NAME

FIRST NAME

INITIAL

BIRTHDATE

YOUR SOCIAL SECURITY NO.

PLACE LABEL IN BLOCK

SPOUSE’S LAST NAME

FIRST NAME

INITIAL

BIRTHDATE

SPOUSE’S SOCIAL SECURITY NO.

NON-OBLIGATED

SPOUSE

IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REPRESENTATIVE, ETC.)

TELEPHONE NUMBER

YOURSELF

(

)

–

YOUR SPOUSE

PRESENT HOME ADDRESS

CITY, TOWN OR POST OFFICE, STATE AND ZIP CODE

AMENDED

RETURN

How do you qualify for the property tax credit or refund?

(You must check a qualification to be eligible for a credit or refund.) Check

only one.

Required copies of letters, forms, cards, etc. must be included with return.

C. 100% Disabled

(YOU MUST ENCLOSE A COPY OF A LET-

A. 65 years of age or older

TER FROM SOCIAL SECURITY ADMINISTRATION, FORM

B. 100% Disabled Veteran

(YOU MUST ENCLOSE A

SSA-1099 OR A COPY OF YOUR MEDICARE CARD.)

COPY OF THE LETTER FROM DEPARTMENT OF

D. 60 years of age or older and received surviving spouse bene-

VETERANS AFFAIRS.)

fits.

(YOU MUST ENCLOSE A COPY OF FORM SSA-1099.)

Single

Married — Filing Combined

Married — Living Separate for Entire Year (see instructions)

SECTION A:

Complete only Section A if you did not file a Form MO-1040 and your only sources of income are

from social security, pensions and annuities, dividends, interest income or public assistance.

Otherwise, please complete both Section A, Page 1 and Section B, Page 2.

00

1. Did you receive social security benefits? If so, enter the amount before any deductions. . . . . . . . . . . . 1

Enclose

Form

2. Did you receive pensions and annuities, dividends or interest income? If so, enter total amount

SSA-1099

00

received. (If filing Form MO-1040, enter amount not included on Form MO-1040.) . . . . . . . . . . .

2

Enclose

3. Did you receive public relief, public assistance, SSI, AFDC payments or unemployment

Form

00

benefits? If so, enter the total amount received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

1099-R

Enclose

4. Did you receive any other income not listed on Lines 1-3? If so, complete

00

Form SSA-

Section B on reverse side and enter amount from Section B, Line F here. . . . . . . . . . . . . . . . . . . .

4

1099 or Letter

00

5. TOTAL household income — add Lines 1 through 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

from SSA, if

applicable

6. Are you married and filing a combined claim with your spouse? (You must report both

00

incomes.) If so, enter $2,000; otherwise, enter zero (0). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

7. Net household income — (Subtract Line 6 from Line 5.) If the total is over $25,000,

00

no credit or refund is allowed — Do not file this claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

Enclose Real

8. Did you own your home? If so, enter the total amount of real estate tax that you paid for your

Estate

home less special assessments. (Complete the worksheet on page 14 if you own more than

Tax Receipt

five (5) acres, a mobile home, a home business or share your home.) . . . . . . . . . . . . . . . . . . . . . . . 8

00

Enclose Form

948 (if more

9. Did you rent your home? If so, enter amount from Section C, Line 7

than 5 acres)

or from Form MO-CRP, Line 7. (If Line 9 is more than Line 7,

00

Enclose Form

=

00

enclose rent payment explanation.) . . . . . . . . . . . . . . . . . . . .

x 20%

. . . 9

MO-CRP, Rent

00

10. Total tax and/or rent—add Lines 8 and 9 and enter the total or $750, whichever is less . . . . . . . . . . 10

Receipts

00

11. PROPERTY TAX CREDIT (apply Lines 7 and 10 to table on pages 19 and 20) . . . . . . . . . . . . . . . . . . . . . . . . . . 11

12. PHARMACEUTICAL TAX CREDIT (If required to file Form MO-1040, enter “0” here;

YOURSELF

YOUR SPOUSE

figure your credit on Form MO-1040.) If not filing Form MO-1040, enter up to

+

=

00

00

00

$200 for each claimant 65 years of age or older.

MUST BE AGE 65 OR OLDER

12

00

13. TOTAL CREDIT OR REFUND (add Lines 11 and 12; enter here and on Form MO-1040, Line 38.)

13

. . . . . . . . . . .

Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. Declaration of pre-

parer (other than taxpayer) is based on all information of which he has any knowledge. As provided in Chapter 143 RSMo, a penalty of up to $500.00 shall be imposed on any individual who files a frivolous return.

I authorize the Director of Revenue or delegate to discuss my return

PREPARER’S TELEPHONE

and attachments with the preparer or any member of his/her firm.

YES

NO

YOUR SIGNATURE

DATE

PREPARER’S SIGNATURE (OTHER THAN TAXPAYER)

FEIN, SSN OR PTIN

DOR

ONLY

SPOUSE’S SIGNATURE (IF FILING COMBINED, BOTH MUST SIGN EVEN IF ONLY ONE HAD INCOME)

PREPARER’S ADDRESS (AND ZIP CODE)

DATE

S

P

MO 860-1089 (11-2000)

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