Form 54-036a - Iowa Special Assessment Credit Claim - 2009
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Iowa Department of Revenue
2009 Iowa Special Assessment Credit Claim
Claimant’s Last Name
Claimant’s First Name
Claimant’s Social Security Number
Claimant’s Birth Date
County Number
/
/
/
/
Spouse’s Last Name
Spouse’s First Name
Spouse’s Social Security Number
Month
Day
Year
____ ____
/
/
Street Address
City, State, Zip Code
Do Not Write In This Space
YES NO
Were you 65 or older or totally disabled and 18 or older as of December 31, 2008?.......................
If yes, you must provide proof of your disability from your doctor or Social
Security office describing your disability and the date it began.
“Household Income” includes the income of the claimant and the claimant’s spouse, if living together,
and monetary contributions received from any other person living with the claimant.
Use Whole DOLLARS Only
2008 Household Income
0
0
,
1. Wages, salaries, tips, etc. _______________________________________
.
0
0
,
2. In-kind assistance for housing expenses ____________________________
.
0
0
,
3. Title 19 Benefits (excluding medical benefits) _______________________
.
0
0
,
4. Social Security income _________________________________________
.
0
0
,
5. Disability income _____________________________________________
.
0
0
,
6. All pensions and annuities ______________________________________
.
0
0
,
7. Interest and dividend income ____________________________________
.
8. Profits from businesses and/or farming and capital gains
0
0
,
If less than zero, enter 0 (see instructions) __________________________
.
0
0
,
9. Money received from others living with you (see instructions) __________
.
0
0
,
10. Other income (Read instructions before making this entry) _____________
.
0
0
,
11. Total lines 1-10 _______________________________________________
.
0
0
,
12. Medical and Care Expenses (see instructions) _______________________
.
0
0
,
13. SUBTRACT line 12 from line 11, enter here ________________________
.
(If more than $10,319 No Credit is Allowed)
This is your total household income
Do not enter an amount on line 12 unless you are totally disabled and incurred
For Use By
County Treasurer Only
medical or care expenses attributable to your disability. List below the nature
Installment
and amount of each expense included on line 12.
Number ___________________
_____________________________________________________________
Annual Special
_____________________________________________________________
Assessment
I declare under penalty of perjury that I have reviewed this claim and to the
Payment __________________
State
best of my knowledge and belief, it is true, correct and complete.
Reimbursement _____________
________________________________________
_________
( ____ ) ________________________
Claimant’s Signature
Date
Claimant’s Telephone Number
This Claim Must Be Filed With Your County Treasurer by September 30, 2009
54-036a (9/4/08)
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