Form Tc-40cb - Renter Refund Application (Circuit Breaker Application) - 2013 Page 2
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1
2Section 4 - Rent Information
List each place you rented during 2012. If you received rental assistance, you can only claim the portion of rent you paid.
Provide documented proof (i.e receipts, bank copy of canceled checks) showing how much rent was paid.
Address of apartment or mobile/home
Total rent
Name and telephone number
Monthly rent
Date rented in 2012
Total
lot (include apartment or lot number)
of landlord or manager
you paid
you paid
from - to
months
Are utilities included in rent?
None
Gas
Electric
Are utilities included in rent?
None
Gas
Electric
Are utilities included in rent?
None
Gas
Electric
Are utilities included in rent?
None
Gas
Electric
Total rent you paid in 2012
Under state and federal law we are prohibited from processing this application
Section 5 - Residency Status of Applicant
or issuing a credit to any person who fails to provide this information.
Check one (providing false information subjects the signer to penalties for perjury):
1.
I am a U.S. citizen and have provided my Social Security Number on the front of this form.
2.
I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully.
I-94 Number*: _ __ _ _ _ _ _ _ _ _ _ _ _ _
If you checked box 2, you must file this form
Alien Registration Number*: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
in person and bring proof of your I-94 Number
*The I-94 (arrival/departure) number and the Alien Registration
and Alien Registration Number.
Number are issued by the U.S. Citizenship and Immigration Service.
Under penalties of perjury, I declare that I am a U.S. citizen OR that I qualify under 8 U.S.C 1641 and am present in the
United States lawfully.
Signature of applicant
Date signed
X
Section 6 - Certification and Signature Certify, sign and date.
Under penalties of perjury, I declare to the best of my knowledge and understanding, this information is true, correct
and complete.
Signature of spouse
Date
Signature of applicant
Date
X
X
Preparer's name and address or organization (if not applicant)
Preparer's telephone number
Send this application to Taxpayer Services Division, Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800
Renter Refund Schedule
For More Information Contact:
2012 Household Income Limits
Renter Refund
Maximum
Golden Years Center (Bountiful) 801-295-3479
% of rent
Renter Refund
Lower
Upper
Salt Lake County Division of Aging 801-538-3910
$0
$10,433
9.5%
$909
Heritage Center (Clearfield) 801-525-5080
10,434
13,913
8.5%
793
Davis County Aging Services 801-525-5050
13,914
17,389
7.0%
680
Autumn Glows Center (Kaysville) 801-544-1235
17,390
20,867
5.5%
509
Utah State Tax Commission 801-297-6254 or outside Salt Lake
20,868
24,347
4.0%
396
24,348
27,618
3.0%
227
area, 1-800-662-4335 or on the web at tax.utah.gov
27,619
30,688
2.5%
112
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Parent category: Financial