Form Tc-40cb - Renter Refund Application (Circuit Breaker Application) - 2013
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1
22013
Utah State Tax Commission
Renter Refund Application
TC-40CB
(Circuit Breaker Application)
Rev. 4/13
Send this application to Taxpayer Services Division, Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800
Renters and Mobile Homeowners applying for lot rental refund, file this application with the Utah State Tax
Commission by December 31, 2013.
Homeowners and Mobile Homeowners applying for property tax credit must file TC-40CY with the county where
the property is located by September 1, 2013.
Applicants who check box 2 in Section 5 (back of form) must file this form in person.
Section 1 - Applicant's Name If more than one person lives in a household, only one person may file an application.
Applicant's Last Name
Applicant's First Name
Middle Initial
Birth Date
Social Security Number
Spouse's Last Name (if spouse is living)
Spouse's First Name
Middle Initial
Social Security Number
Birth Date
Address
City
State
ZIP Code
Daytime Telephone Number
County
Section 2 - Household Income
Must include ALL gross income received from all household members.
Complete and add lines A through I and enter the total on line J. Household income is income received during 2012 from all members
living in the household as of January 1, 2012, not just the applicant. A “household” is an association of all people living in the same
dwelling, sharing furnishings, facilities, accommodations and expenses. Send supporting income documentation for information
provided below.
Total members in household as of January 1, 2012
F. Government assistance
A. Wages/salaries/tips/other compensation
F
A
G. Unemployment, worker’s compensation
(W-2, 1099Misc, etc.)
G
H. Business, rental, farm income
B. Total interest income, dividends
H
B
(Include copy of federal return and all
(taxable/nontaxable)
schedules. This amount will be reviewed.)
C. Pensions, annuities-include IRAs
C
I. Other income received under Utah Code
I
(taxable/nontaxable)(Include a copy of federal
Section 59-2-1202 such as alimony, nontaxable
return and all schedules. This amount will be reviewed.)
interest, etc. (send supporting documentation)
D. Social Security/Railroad retirement
D
J. Total 2012 household income from
J
(taxable/nontaxable) (send supporting
all sources (add lines A through I)
documentation)
You do not qualify if the verified amount on line J exceeds $30,688. The
E. Current year capital gain or loss
Tax Commission will review and determine eligibility for refund. You
E
(Include copy of federal return and all
may be required to submit additional information to support your claims.
schedules. This amount will be reviewed.)
Section 3 - Do You Qualify For A Refund Applicant must answer questions 1 through 5.
1. Were you age 66 or older on or before December 31, 2012, or are you a widow or widower?
Yes
No
Enter spouse's date of death: _____________. Attach a copy of your deceased spouse's death
(Go on to
(STOP, do not
send form)
question 2)
certificate if this is the first year you are claiming a refund as a widow or widower.
2.
Is the amount on line J above less than or equal to $30,688? Household Income is income received
Yes
No
during 2012 by all members of a household (not just the applicant) living in the same dwelling, sharing
(Go on to
(STOP, do not
furnishings, facilities, accommodations and expenses as of January 1, 2012.
question 3)
send form)
3.
Did you furnish your own financial support for 2012 and cannot be claimed as a
No
Yes
dependent on someone else's tax return?
(Go on to
(STOP, do not
question 4)
send form)
4.
Did you live in Utah for the entire year of 2012? You must have lived in Utah for the entire
No
Yes
calendar year to be eligible.
(Go on to
(STOP, do not
question 5)
send form)
5.
Are you a mobile homeowner applying for a lot rental refund?
No
Yes
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