Form 150-101-024 - Credit For Home Care Of A Person Age 60 Or Older

PART II

HOUSEHOLD INCOME

List your household income and the household income of the person you care for in the space below. Household income is the taxable

and nontaxable income of both spouses (living in the same household). The full-year resident tax booklet has more information on household

income, or see the Elderly Rental Assistance (ERA) Form 90R instructions.

NOTE: The support you provide for the person you care for is considered a gift. The amount

you pay over $500 must be included in their household income. Enter it on line 8.

YOUR

HOUSEHOLD INCOME OF

TYPE OF INCOME

HOUSEHOLD INCOME

PERSON YOU CARE FOR

1. Wages, salaries, and other pay for work ......................

1. _________________________

1. _______________________

2. Interest, dividends (total taxable and nontaxable) ........

2. _________________________

2. _______________________

3. Business net income (loss limited to $1,000) ...............

3. _________________________

3. _______________________

4. Total gain on property sales (loss limited to $1,000) ....

4. _________________________

4. _______________________

5. Social Security, SSI, and Railroad Retirement .............

5. _________________________

5. _______________________

6. Pensions, annuity (taxable and nontaxable) .................

6. _________________________

6. _______________________

7. Adult and Family Services (welfare) .............................

7. _________________________

7. _______________________

8. Gifts and grants over $500 ...........................................

8. _________________________

8. _______________________

9. Other (specify) _______________________________

9. _________________________

9. _______________________

10. TOTAL HOUSEHOLD INCOME ...................................

10. _________________________

10. _______________________

If your household income is $17,500 or more, or if the person you care for has household income of more than $7,500, you are not

eligible for the credit.

11. You may claim food, clothing, medical, and transportation expenses you pay or incur for the person you care for. The expenses

must be paid or incurred during the period certified by the Seniors and People with Disabilities Division. Amounts you pay for lodging

don’t qualify. Subtract any reimbursement received from insurance or from the person you care for when you figure the costs you paid.

A. Food (includes purchase and preparation) ...................................................... $ __________________________

B. Clothing (includes purchase, cleaning, and repairing) ..................................... $ __________________________

C. Medical care (includes doctor fees, medicine, special equipment, etc.) .......... $ __________________________

D. Transportation (includes transportation for medical and personal needs) .......

$ __________________________

12. Total expenses paid (add the amounts on lines A, B, C, and D) ................................................. 12. ________________________

13. Multiply the amount on line 12 x .08 (8 percent) .......................................................................... 13. ________________________

$250

14. Maximum credit ............................................................................................................................ 14. ________________________

15. Allowable credit (lesser of line 13 or line 14) ............................................................................... 15. ________________________

150-101-024 (Rev. 1-03)

KEEP A COPY OF THIS FORM WITH YOUR TAX RECORDS.

Form 150-101-024 - Credit For Home Care Of A Person Age 60 Or Older - 2003 Page 2

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