California Form 9000r - Renter Assistance Claim - 2002 Page 2
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1
2On line 8 through line 13 enter your total household income for the 2001 calendar year.
STEP D
See instructions on page 8 and page 9.
(Dollars)
(Cents)
Income of
household
8. Social Security and/or Railroad Retirement . . . . . . . . .
members
8.
9. Interest, Dividends, and/or Gain (or Loss) . . . . . . . . . .
9 .
10. Pensions and/or Annuities . . . . . . . . . . . . . . . . . . . . . . .
10.
11. SSI/SSP, AB, and ATD (Gold Check). See page 9 . . . . . .
11.
(full year total)
12. Rental and Business Income (or Loss) . . . . . . . . . . . . .
12.
See page 9. Do not enter your monthly rent payments.
13. Other Income (including wages). See page 9 . . . . . . . .
13.
14. SUBTOTAL. Add line 8 through line 13 . . . . . . . . . . . . . . .
14.
STEP E
Adjustments
15. Adjustments to Income. See page 10 . . . . . . . . . . . . . .
15.
to income
STEP F
16. TOTAL HOUSEHOLD INCOME IN 2001.
•
Total household
Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . .
16.
income
If line 16 is more than $37,119, stop. You do not qualify.
STEP G
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. (Cannot exceed $347.50)
claimed
See page 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17.
Reminder
If this is your first year filing a Renter Assistance claim and you did not receive SSI,
please 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)
STEP H
Caution: To avoid delay of your check, be sure to provide all requested information, sign below, and
mail to: FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
Signature,
date, and
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information neces-
sary to process my claim, against information gathered from public records, the files of the Department of Health Services,
telephone
and other state or 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.
‘ ‘ ‘ ‘ ‘
Sign Here
X___________________________________________________________ Date________________
Claimant’s signature
(
)
Claimant’s Daytime Telephone Number ________________________________________
Date
Preparer’s social security number/PTIN
PREPARER’S
Paid
Check if
SIGNATURE
self-employed
Preparer’s
FEIN/PTIN
Use Only
FIRM’S NAME (OR YOURS, IF
SELF-EMPLOYED) AND ADDRESS
TELEPHONE (
)
Do not write in this space
Do not write in this space
L L L L L
D D D D D
I I I I I
A A A A A
R R R R R
RES
RES
RES
RES
RES
Side 2 FTB 9000R 2002
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