Form Tc-40cb - Renter Refund Application (Circuit Breaker Application) - 2009
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2009
Utah State Tax Commission
Renter Refund Application
TC-40CB
(Circuit Breaker Application)
Rev. 5/09
Return this application to Taxpayer Services Division
Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800
Renters and Mobile Homeowners applying for lot rental refund, file this application with the Utah State Tax
Commission by December 31, 2009.
Homeowners and Mobile Homeowners applying for property tax credit, must file TC-40CY with the county where
the property is located.
Applicant's Name
If more than one person lives in a household, only one person can file an application.
Applicant's Last Name
Applicant's First Name
Middle Initial
Birth Date
Social Security Number
Spouse's Last Name (if spouse is living)
Spouse's First Name
Middle Initial
Social Security Number
Birth Date
Address
City
State
ZIP Code
Daytime Telephone Number
County
Do You Qualify For A Refund?
APPLICANT must answer questions 1 through 5.
1. Were you age 65 or older on or before December 31, 2008, OR are you a widow or widower?
Yes
No
Enter spouse's date of death: _____________. Attach a copy of your deceased spouse's death
(Go on to
(STOP, you do
certificate if this is the first year you are claiming a refund as a widow or widower.
question 2)
NOT qualify)
Total members in household as of Jan. 1, 2008
2. 2008 Household Income (from all household members living in the household as of January 1, 2008, not just applicant).
J. Total 2008 household income from
J
A. Wages/salaries/tips/other compen.
A
all sources (add lines A through I)
B. Total interest, dividends
B
Are you eligible to claim a dependent as a personal exemption on
(taxable/nontaxable)
your 2008 federal income tax return?
C. Pensions, annuities (incl. IRAs)
C
No (enter total 2008 household income from line J to line K)
D. Soc. Sec./Railroad retirement
D
Yes (subtract $1,000 from line J and enter result on line K)
(taxable/nontaxable)
E. Capital gains, loss carry forwards
E
K. Adjusted 2008 household income
K
F. Government assistance
F
G. Unemployment, worker’s comp.
G
You do not qualify if the amount in Box "K" exceeds $28,732.
H. Business, rental, farm income
H
I. Other income (alimony, etc.)
I
No
Yes
Is the amount in line K above less than or equal to $28,732? Household Income is income
(Go on to
(STOP, you do
received during 2008 by all members of a household (not just the applicant) living in the same
question 3)
NOT qualify)
dwelling, sharing furnishings, facilities, accommodations and expenses as of Jan. 1, 2008.
3. Did you furnish your own financial support for 2008 and cannot be claimed as a
No
Yes
dependent on someone else's tax return?
(Go on to
(STOP, you do
question 4)
NOT qualify)
No
Yes
4. Did you live in Utah for the entire year of 2008? You must have lived in Utah for the entire
(Go on to
(STOP, you do
calendar year to be eligible.
question 5)
NOT qualify)
Yes
No
5. Are you a mobile homeowner applying for a lot rental refund?
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