Tax And Rent Refund Application - Maine Revenue Services - 2004
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1
2Tax and Rent Refund Application
Maine
00
Revenue Services
*0403700*
PO Box 9116
Do not use red ink.
Use blue or black ink.
Augusta, Maine 04332-9116
IMPORTANT!
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You must enter your SSN(s) and
date(s) of birth below.
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Your Social Security Number
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Your Date of Birth
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Spouse’s Social Security Number
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Spouse’s Date of Birth
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If applicant named above died during 2003 or 2004,
Your Telephone Number
enter date of death: ....................................................
_______ – ______ – _______
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-
(Month)
(Day)
(Year)
If spouse died during 2003 or 2004,
enter date of death: ....................................................
_______ – ______ – _______
(Month)
(Day)
(Year)
BE SURE TO ANSWER “Yes” or “No” to each question.
Yes No
YOUR REFUND WILL BE DELAYED IF YOUR APPLICATION IS NOT COMPLETE.
1a. Do you receive any federal disability payments such as social security disability benefits or supplemental
security income disability benefits? ............................................................................................................................ 1a.
1b. Does your spouse receive any federal disability payments such as social security disability benefits or
supplemental security income disability benefits? ..................................................................................................... 1b.
1c. Were you a Maine resident for all of 2003? ................................................................................................................ 1c.
1d. Did you have a home or apartment in Maine for all of 2003 and live in your home or apartment for at least
6 months of 2003? ...................................................................................................................................................... 1d.
2. Physical location of property where you lived during 2003 (if different from Mailing Address above): _____________________
_______________________________________________________________________________________________________
If you paid rent in 2003, list your landlord’s name and telephone number: ____________________________________________
_______________________________________________________________________________________________________
3. Dependents. How many dependents do you have
(DO NOT INCLUDE YOU OR YOUR SPOUSE)? ............
List your dependents below. If you have more than 2 dependents, list them on a separate sheet of paper.
Dependent’s First Name
Dependent’s Social Security Number
3a. Does this dependent receive any federal
Yes No
-
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disability payments such as social security
disability benefits or Supplemental security
Dependent’s Last Name
Dependent’s Date of Birth
income disability benefits? .................................
-
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Dependent’s First Name
Dependent’s Social Security Number
3b. Does this dependent receive any federal
Yes No
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-
disability payments such as social security
Dependent’s Last Name
Dependent’s Date of Birth
disability benefits or Supplemental security
-
-
income disability benefits? .................................
,
4. Enter property tax assessed on your home in 2003 (See instructions on pages 4 and 5) ...... 4.$
.
(If your property tax bill is more than $1,800, attach the copy of the tax bill that has your name on it.)
a. Did you rent part of your home to others or use part of it for a business? ..................................... 4a.
Yes
No
b. Was your home on a rented lot? ..................................................................................................... 4b.
Yes
No
,
.
5. Enter total rent you paid on your home or lot in 2003 (Do not include mortgage payments) ..... 5.$
(If your rent is over $7,200, attach copies of your rent receipts.)
a. Does the rent on line 5 include heat? ............................................................................................. 5a.
Yes
No
b. Was your rent reduced or paid in part by the government? ........................................................... 5b.
Yes
No
Turn page over and fill out other side
Printed under Approp. 010 18F 1384.01
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