California Form 9000r - Renter Assistance Claim - 2002
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1
2YEAR
CALIFORNIA FORM
Renter
2002
9000R
Assistance Claim
(for income received in 2001)
Your first name
Initial
Last name
STEP A
Spouse’s first name
Last name
Initial
Name,
address,
Apt. no.
PMB no.
and
Present home address — number and street, PO Box or rural route
social
security
State
ZIP Code
City, town, or post office
-
number
Your social security number
Spouse’s social security number
IMPORTANT:
SSN
-
-
-
-
Your social security number
is required.
STEP B
•
1. Are you a United States citizen? Check “Yes” or “No” . .
1.
NO
YES
If you checked “Yes,’’ skip line 2 and go to line 3.
Filing
If you checked “No,’’ go to line 2.
•
Status
2. Benefit Eligibility for Noncitizens . . . . . . . . . . . . . . . . . . . .
2a.
Alien Status Code
I f you are not a citizen of the United States, go to page 19. If you
have a qualifying alien status for the United States, enter your
•
Alien Registration
2b.
alien status code from the chart on page 19 on line 2a. Then
Number
enter your alien registration number on line 2b and your date
•
of entry into the United States on line 2c.
2c.
Date of Entry
•
3. Enter your date of birth (example: 0 5/ 2 1 / 1 9 3 8) . . . . . .
3.
MM DD Y Y Y Y
Date of Birth
You must enter your date of birth
4. Check the appropriate box if you were one of the following on
December 31, 2001:
•
A.
62 years or older
A
•
B.
Under 62 and blind
B
•
C.
Under 62 and disabled (not blind)
C
See the instructions on page 6, line 4a if you turned 62 on 1/1/02. See
instructions on page 6 and page 7 to see if you must attach a proof
document to your claim. If you cannot check one of the boxes, STOP
HERE. You do not qualify to file for a Renter Assistance claim.
STEP C
5. Enter the total number of months during 2001 that you
lived in a qualified rented residence in California.
•
________months
Rental
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
Information
6. If the address where you lived during 2001 is different than the address you
entered in Step A, or if the address in Step A is a post office box, enter your 2001
Complete
residence address. (If more than one rented residence attach a list.)
line 5
Street Address
City
through
line 7.
¼
_________________________________________________________________________________________
State and ZIP Code
¼
/
/
/
/
___________________________________________
________________
________________
RENTED FROM
TO
7. Enter the name, address, and telephone number of your landlord or the person
to whom you paid rent during 2001.
NAME ___________________________________________________________________________________________________________
ADDRESS ______________________________________________________________________________ APT. OR UNIT NO._________
_____________________
CITY ________________________________________________________ STATE and ZIP CODE_________
TELEPHONE (
) ____________________________________
For Privacy Act Notice, see Page 12.
Complete Side 2, Step D Through Step H.
FTB 9000R 2002 Side 1
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