California Form 9000r - Renter Assistance Claim - 2005 Page 2
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1
2On line 8 through line 13 enter your household income for the 2004 calendar year below.
STEP 5
Include the income of your spouse and certain other household members. See
Yearly income
instructions for other household members on page 6 and page 7.
(Dollars)
(Cents)
of household
members
8. Social Security and/or Railroad Retirement . . . . . . . . .
8.
9. Interest, Dividends, and/or Gain (or Loss) . . . . . . . . . .
9.
10. Pensions, Annuities, and IRA distributions . . . . . . . . .
10.
11. SSI/SSP (Gold Check). See page 7 . . . . . . . . . . . . . . . . .
11.
(full-year total)
12. Rental and Business Income (or Loss) . . . . . . . . . . . . .
12.
See page 7. Do not enter your monthly rent payments.
13. Other Income (including wages). See page 7 . . . . . . . .
13.
14. SUBTOTAL. Add line 8 through line 13 . . . . . . . . . . . . . . .
14.
STEP 6
Adjustments
15. Adjustments to income. See page 7 . . . . . . . . . . . . . . . .
15.
to income
16. TOTAL HOUSEHOLD INCOME IN 2004.
STEP 7
•
Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . .
16.
Total household
If line 16 is more than $39,699, STOP. You do not qualify.
income
Do you receive Temporary Assistance for Needy Families,
formerly Aid to Families with Dependent Children (AFDC)?
YES
NO
You do not have to complete line 17. If you stop here, we will figure the amount of
STEP 8
assistance for you.
Renter
assistance
17. Renter assistance claimed. (Cannot exceed $347.50)
claimed
See page 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17.
Reminder
If this is your first year filing a Renter Assistance claim and you did not receive SSI, please
provide proof of your age, disability, or blindness.
If you filed a claim last year and are under 62 years old, you will need to provide proof of your
temporary disability if you did not receive SSI. (This is an annual requirement.)
Caution: To avoid delay of your check, be sure to provide all requested information, sign below, and
STEP 9
mail to: FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
Signature,
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information neces-
date, and
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 Renter 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. By signing this claim, I authorize the Franchise Tax Board to mail any
assistance to which I am entitled, pursuant to this claim, to the address listed in step one.
‘ ‘ ‘ ‘ ‘
X___________________________________________________________ Date________________
Sign Here
Claimant’s signature
(
)
•
Claimant’s Daytime Telephone Number
________________________________________
Date
Check if
Preparer’s social security number/PTIN
self-employed
PREPARER’S
SIGNATURE
Paid
FEIN
Preparer’s
FIRM’S NAME (OR YOURS, IF
Use Only
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 9000R 2005
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