Form Tc-40cb - Renter Refund Application - 2001
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1
22001
Utah State Tax Commission
Renter Refund Application
TC-40CB
(Circuit Breaker Application)
Rev. 1/01
For more information, contact your county; or for a listing of other agencies
to contact, see the reverse side of this form (at the bottom).
Renter's Name
If more than one person lives in a household, only one person can file an application.
Claimant's Last Name
Claimant's First Name
Middle Initial
Birth Date
Social Security Number
Spouse's Last Name (if spouse is living)
Spouse's First Name
Middle Initial
Birth Date
Social Security Number
Address
City
County
State
ZIP Code
Daytime Telephone Number
Do You Qualify For A Refund?
Renters: You should file this application with the Utah State Tax Commission by December 31, 2001.
Homeowners and Mobile Homeowners: You should first file for property tax relief through your county government. Contact your
county government to obtain the application and filing deadline.
ALL APPLICANTS must answer questions 1 through 4.
1. Will you be age 65 or older before December 31, 2001? OR Are you a widow or widower who is
Yes
No
NOT REMARRIED? Enter spouse's date of death: _____________. Include a copy of the death
(Go on to
(STOP, you do
certificate if this is the first year you are claiming benefits as a widow or widower.
question 2)
NOT qualify)
2. 2000 Household Income (from all household members).
Taxable Income
Non-taxable Income
A. Wages/salaries
A
E. Social Security/other government programs
E
B. Pensions/annuities
B
F. Capital gains/pensions/annuities
F
C. Interest/dividends/trusts
C
G. Interest/dividends/trust income
G
D. Alimony/other income
D
H. Loss carryforwards/rental depreciation
H
I.
I
Total 2000 household income from all sources
(add lines A through H)
I
Total members in household
You do not qualify if the amount in Box
exceeds $23,108.
I
Is the amount in Box
above less than or equal to $23,108? Household Income is income
Yes
No
received during 2000 by all members of a household (not just the claimant) living in the same
(Go on to
(STOP, you do
question 3)
NOT qualify)
dwelling, sharing furnishings, facilities, accommodations and expenses.
3. Did you furnish your own financial support for 2000. If you are claimed as a dependent on
Yes
No
someone's tax return, you did not furnish your own financial support, and do not qualify.
(Go on to
(STOP, you do
question 4)
NOT qualify)
4. Did you live in Utah for the entire year of 2000? You must have lived in Utah for the entire calendar
No
Yes
year to be eligible.
(Go on to next
(STOP, you do
page)
NOT qualify)
This Box for Tax
Commission Use Only
R
40CB.FRM
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