Form 104 Ptc - Colorado Property Tax/rent/heat Rebate Application - 2016 Page 9
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12Form 104 PTC (07/26/16)
*160104PT29999*
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Name
Account Number
List in the boxes below the TOTAL amount(s) received January through December 2016. If joint, add together the income
for both parties before listing the total. DO NOT enter your monthly amounts.
1. Enter the number of months (1-12) you received Medicare during 2016. If your
Medicare premiums were paid by Medicaid, enter 0.
1
00
2. Social Security, SSI and/or A.N.D. benefits
2
00
3. Colorado Old Age Pension
3
00
4. Private or VA pension payments received
4
00
5. Wages, salaries and tips
5
00
6. Interest and dividends
6
00
7. Other income, Explain
7
Enter your 2016 property tax, rent and heat expenses.
00
8. If you paid 2015 property tax in 2016, enter amount here.
8
00
9. If you paid rent, enter the total for the year here
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10. If you paid heat or fuel expenses, enter the total for the year here
10
00
11. Are your meals included in your rent payments?
11
00
OR
No
Yes
Only part of the year enter amount
12. Did you pay rent for a property tax exempt unit?
No
Yes
OR
Only part of the year enter amount
12
00
13. Was your heat included in your rent payments?
00
13
OR
No
Yes
Only part of the year enter amount
Direct
Type:
Checking
Savings
Routing Number
Deposit
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.
Mail to: Colorado Department of Revenue,
Your Signature
Date
(MM/DD/YY)
Denver, CO 80261-0005
Spouse/Partner Signature
Date
Prepared by
(MM/DD/YY)
IMPORTANT — You must also complete and sign the affidavit on page 8.
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