Form Tc-40cb - Renter Refund Application (Circuit Breaker Application) - 2009 Page 2
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Section One - Rent Information
Complete this section for each place you rented during 2008. If you received rental assistance, you can only claim the
portion of rent you paid.
Address of apartment or mobile/home
Name and telephone number
Monthly rent
Total rent
Date rented in 2008
Total
lot (include apartment or lot number)
you paid
you paid
of landlord or manager
from - to
months
Utilities included in rent?
None
Gas
Electric
Utilities included in rent?
None
Gas
Electric
Utilities included in rent?
None
Gas
Electric
Utilities included in rent?
None
Gas
Electric
Total rent you paid in 2008 (This amount should not include the cost of utilities)
Section Two - Residency Status of Applicant
Under state and federal law we are prohibited from processing this application or issuing a credit to any person who fails to provide
this information. The Alien Registration Number and the I-94 numbers are issued by the U.S. Citizenship and Immigration Service.
Check one:
I am a U.S. citizen. SSN: __ _ __ __ _ __ __ _ __ _
I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully.
I-94 #: ___ ___ ____ ___ ___
Alien #: _ ___ ____ ___ ___ _
Section Three - Certification and Signature
Certify, sign and date.
Under penalties of perjury, I declare to the best of my knowledge and understanding, this information is true, correct
and complete.
Signature of spouse
Date
Signature of applicant
Date
X
X
Preparer's name and address or organization (if not applicant)
Preparer's telephone number
Return this application to Taxpayer Services Division, Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800
Renter Refund Schedule
For More Information Contact:
2008 Household Income Limits
Renter Refund
Maximum
Golden Years Center (Bountiful) 801-295-3479
% of rent
Renter Refund
Lower
Upper
Salt Lake County Division of Aging 801-468-2480
$0
$9,768
9.5%
$851
Heritage Center (Clearfield) 801-773-7065
9,769
13,026
8.5%
742
Davis County Aging Services 801-451-3377
13,027
16,281
7.0%
637
Autumn Glows Center (Kaysville) 801-451-3329
16,282
19,537
5.5%
477
Utah State Tax Commission 801-297-2200 or outside Salt Lake
19,538
22,795
4.0%
371
22,796
25,858
3.0%
212
area, 1-800-662-4335 or on the web at tax.utah.gov
25,859
28,732
2.5%
105
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Parent category: Financial