California Form 9000r - Renter Assistance Claim - 2008 Page 2
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1
2To enter monthly amounts, check the monthly box.
STEP 5
On line 8 through line 13 below, enter your household income for the 2007 calendar year.
Include the income of your spouse/RDP and certain other household members.
Yearly
See instructions for other household members on page 7 and page 8.
(Dollars)
(Monthly)
income of
m
m
Monthly
Yearly
household
00
00
8. Social Security and/or Railroad Retirement . . . . . . . . .
8.
members
00
00
9. Interest, Dividends, and/or Gain or (Loss) . . . . . . . . . . .
9.
00
00
10. Pensions, Annuities, and IRA distributions . . . . . . . . . . 10.
00
00
11. SSI/SSP, (gold Check). See page 7 . . . . . . . . . . . . . . . . . . . 11.
00
00
12. Rental and Business Income or (Loss) . . . . . . . . . . . . . . 12.
See page 7 .
13. Other Income (including wages, spouse’s/RDP’s
00
00
income) See page 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.
$0
14. Subtotal. Add line 8 through line 13 . . . . . . . . . . . . . . . . . . 14.
00
00
$0
15. Adjustments to Yearly Income. See page 8 . . . . . . . . . . 15.
00
$0
(If you do not have any adjustments to income,
enter zero and go to line 16 .)
16. TOTAL YEARLY HOUSEHOLD INCOME IN 2007.
•
00
Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . .
16.
$0
If line 16 is more than $44,096, STOP . You do not qualify.
Do you receive Temporary Assistance to Needy Families,
YES
NO
formerly Aid to Families with Dependent Children (AFDC)? . . . . . .
STEP 6
You do not have to complete line 17. If you stop here, we will figure the amount of
assistance for you.
Renter
assistance
17. Renter assistance claimed. (Optional)
claimed
$0.00
(Cannot exceed $347.50) See page 13 . . . . . . . . . . . . . . . . . . . . 17.
Reminder
If this is your first year filing a Renter Assistance claim and you did not receive SSI, provide proof of
your age, disability, or blindness .
If you filed a claim last year and are under 62 years old, you will need to provide proof of your temporary
disability if you did not receive SSI . (This is an annual requirement .)
Caution: To avoid delay of your check, be sure to provide all required information, sign below, and mail to:
STEP 7
FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
Signature,
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information necessary to
date, and
process my claim, against information gathered from public records, the files of the Department of health Services, and other state or
telephone
federal agencies to confirm my eligibility for the Renter Assistance Program .
number
Under penalties of perjury, I declare that this claim and all statements regarding my eligibility and citizenship or alien status, including
accompanying schedules and any additional information I may provide to the Franchise Tax Board are to the best of my knowledge,
true, correct, and complete . By signing this claim, I authorize the Franchise Tax Board to mail any assistance to which I am entitled,
pursuant to this claim, to the address listed in step one .
Print Name __________________________________________________________________________
Sign Here
X_______________________________________________________________ Date________________
Claimant’s signature
•
( )
Claimant’s Daytime Telephone Number
________________________________________
Date
Check if
Preparer’s social security number/PTIN
PREPARER’S
self-employed
m
SIgNATURE
Paid
FEIN
Preparer’s
FIRM’S NAME (OR YOURS, IF
Use Only
SELF-EMPLOYED) AND ADDRESS
TELEPhONE (
)
Do not write in this space
Do not write in this space
L
D
I
A
R
RES
Side 2 FTB 9000R 2008
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