Form 104 Ptc - Colorado Property Tax/rent/heat Rebate Application - 2002
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1FORM 104 PTC
(63)
2002 COLORADO PROPERTY
TAX/RENT/HEAT REBATE APPLICATION
The Department of Revenue will calculate and mail one refund check for your rebate within
12 weeks. Inquiries will not be accepted before then. See Page 6 if you wish to calculate the
amount of your rebate.
LAST NAME
FIRST NAME AND INITIAL
SOCIAL SECURITY NUMBER
DECEASED
DATE OF BIRTH
Yourself
MONTH DAY YEAR
YES
Spouse, if joint
YES
Your telephone number
Address
(
)
City
State
ZIP Code
Colorado Drivers License/ID #s
YOU MUST FILE JOINTLY IF YOU ARE MARRIED
AGE OR DISABILITY STATUS
Which of the following applies to you? If none apply, do not fill out or file this form because you do not qualify for this rebate.
If A or B apply, do not check C or D.
A
I (or my spouse) was at least 65 years of age on December 31, 2002.
B
I was a widow or widower at least 58 years of age on December 31, 2002.
C
I was totally disabled for all of
2002
and received payment of full benefits from Social Security, SSI or the
Department of Human Services based solely on such disability.
D
I was totally disabled for all of
2002
and received payment of full benefits from a bona fide public or private plan
or source based solely on such disability. You MUST attach proof of disability (see page 4).
INCOME
List your entire 2002 income from ALL sources. If married, the total income for both spouses must be reported.
(Enter "0" if premiums
1. Enter number of months you received Medicare during 2002 .................................
1
Months
were paid by Medicaid)
2. Social Security and/or SSI benefits received in 2002 ..............................................
2
.00
3. Colorado Old Age Pension payments received in 2002 ..........................................
3
.00
4. Private or VA pension payments received in 2002 ..................................................
4
.00
5. Wages, salaries and tips ..........................................................................................
5
.00
6. Interest and dividends ..............................................................................................
6
.00
7. Other income, Explain ________________________________________ ............
7
.00
EXPENSES
8. If you paid 2001 property tax in 2002, enter amount here .......................................
8
.00
9. If you paid rent in 2002, enter the total for the year here .........................................
9
.00
10. If you paid heat or fuel expenses in 2002, enter the total for the year here ............
10
.00
11. Are your meals included in your rent payments?
No,
Yes,
Only part of the year enter amt.$ ________ .00
OR
12. Did you pay rent for a property tax exempt unit?
No,
Yes,
Only part of the year enter amt.$ ________ .00
OR
13. Was your heat included in your rent payments?
No,
Yes,
Only part of the year enter amt.$ ________ .00
OR
Have your rebate directly deposited (See page 6)
Savings
Type:
Checking
Routing number
Account number
I declare under penalty of perjury in the second degree that to the best of my knowledge and belief the information herein is true,
correct and complete. Furthermore, I authorize the Department of Revenue to contact the appropriate agencies to verify any
information provided on this form and the agencies are hereby authorized to release such information to the Department of Revenue.
Your Signature
Date
MAIL TO: COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0005
Prepared by
Spouse's Signature
Date
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