Form 54-036a - Iowa Special Assessment Credit Claim - 2003
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12003 Iowa Special Assessment
IOWA
Credit Claim
d e pa r t me n t o f R eve n u e a n d F i n a n c e
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
F
Do Not Write In This Space
YES NO
Were you 65 or older or totally disabled and 18 or older as of December 31, 2002?.............................
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, the claimant’s spouse and
monetary contributions received from any other person living with the claimant.
2002 Household Income
Use Whole DOLLAR S Only
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 $9,061 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
medical or care expenses attributable to your disability. List below the nature and
County Treasurer Only
Installment
amount of each expense included on line 12.
Number ___________________
_____________________________________________________________
Annual Special
_____________________________________________________________
Assessment
Payment __________________
I declare under penalty of perjury that I have reviewed this claim and to the best
State
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, 2003
54-036a 06/03/02
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Parent category: Financial