Form Mi-1040cr-7 - Michigan Home Heating Credit Claim - 2012
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Michigan Department of Treasury (Rev. 08-12), Page 1
Issued under authority of Public Act 281 of 1967.
2012 MICHIGAN Home Heating Credit Claim MI-1040CR-7
1 4
0123456789
Print numbers like this
- NOT like this:
Attachment 08
:
1. Filer’s First Name
M.I.
Last Name
2. Filer’s Social Security Number (Example: 123-45-6789)
If a Joint Return, Spouse’s First Name
M.I.
Last Name
3. Spouse’s Social Security Number (Example: 123-45-6789)
Home Address (No., Street or P.O. Box)
City or Town
State
ZIP Code
4. County Code (p. 19)
5. 2012 FILING STATUS:
6. 2012 RESIDENCY STATUS:
*If you checked box “c,” enter dates of Michigan residency in 2012.
Check one.
Check all that apply.
Enter dates as MM-DD-YYYY (Example: 04-15-2012).
FILER
SPOUSE
a.
Single
a.
Resident
2012
2012
FROM:
Married, filing jointly
b.
b.
Nonresident
2012
2012
TO:
Married, filing separately
c.
c.
Part-Year Resident*
13. Exemptions. Enter the number that applies to you,
7. Check the box if your heating costs are currently included in your
your spouse, or your dependents and complete
rent or in someone else’s name (see instructions) ..........................
line 14 below.
8. Check the box if you want your name and address referred to
Personal Exemption
..........................
a.
other government assistance programs for which you may qualify.
(You and your spouse only)
Deaf, Disabled or Blind ...................
b.
Check the box if you or your spouse now receive
9.
Supplemental Security Income (SSI)........................................
Qualified Disabled Veteran ............
c.
Filer
Spouse
Number of children living with you:
10. ENTER YOUR AGE if you are age 60 or older ...
Ages 2 and under .......................
d.
=
Ages 3-5......................................
e.
=
11. How much were you billed for
heat between 11/1/2011 - 10/31/2012? ............
00
Ages 6-18....................................
f.
12. If you lived in one of these CARE facilities (not a senior apartment
=
complex) for all of 2012, check the box and STOP here, see instructions.
Dependent adults, other than
a.
Nursing Home
b.
Adult Foster Care Home
your spouse, who live with you .......
g.
c.
Licensed Home for the Aged
d.
Substance Abuse Center
Add lines 13a through 13g..............
h.
14.
You MUST enter below the name, relationship, Social Security number, and age of all dependents you claimed in line 13, d - g above.
A. Dependent’s Name
B. Dependent’s Relationship to You
C. Social Security Number
D. Age in Years
If you have more than six (6) dependents, complete Home Heating Credit Claim MI-1040 CR-7 Supplemental (Form 4976).
15.
You must check this box to receive a refund from your heat provider for
any overpayment to your heat account, if eligible. See instructions, p. 7.
+
0000 2012 37 01 27 8
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