Tax And Rent Refund Application - Maine Revenue Services - 2005
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1
2Tax and Rent Refund Application
Maine
00
Revenue Services
*0503700*
PO Box 9116
Do not use red ink.
Use blue or black ink.
Augusta, Maine 04332-9116
IMPORTANT!
Your First Name
MI
Your Last Name
You must enter your SSN(s) and
date(s) of birth below.
Spouse’s First Name
MI
Spouse’s Last Name
Your Social Security Number
Mailing Address (PO Box, number, street and apt. no)
-
-
Your Date of Birth
-
-
Spouse’s Social Security Number
City
State
Zip Code
-
-
Spouse’s Date of Birth
-
-
Your Telephone Number
If applicant named above died during 2004 or 2005,
enter date of death: ....................................................
_______ – ______ – _______
-
-
(Month)
(Day)
(Year)
If spouse died during 2004 or 2005,
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 2004? ................................................................................................................ 1c.
1d. Did you have a home or apartment in Maine for all of 2004 and live in your home or apartment for at least
6 months of 2004? ...................................................................................................................................................... 1d.
2. Physical location of property where you lived during 2004 (if different from Mailing Address above): ______________________
_______________________________________________________________________________________________________
If you paid rent in 2004, 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
-
-
disability payments such as social security
Dependent’s Last Name
Dependent’s Date of Birth
disability benefits or supplemental security
-
-
income disability benefits? .................................
Dependent’s First Name
Dependent’s Social Security Number
3b. Does this dependent receive any federal
Yes No
-
-
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 2004 (See instructions on pages 6 and 7) ...... 4.$
(If your property tax bill is more than $2,500, attach the copy of the tax bill that has your name on it.)
a. Did you rent part of your home to others or use part of it for a business? .................................... 4a.
Yes
No
b. Was your home on a rented lot? ..................................................................................................... 4b.
Yes
No
,
.
5. Enter total rent you paid on your home or lot in 2004 (Do not include mortgage payments) ..... 5.$
(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
Revised August 15, 2005
Turn page over and fill out other side
Printed under Approp. 010 18F 1384.01
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