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GENERAL INSTRUCTIONS

PROOF OF DISABILITY:

Food stamps, surplus foods, or other such noncash relief sup-

plied by a governmental agency

If you are filing because of a permanent disability, you must provide

proof of your permanent disability and proof of your age.

Any Property Tax or Rent Rebate check received in 1999

Example:

The amount of any damages because of personal injuries or

If you never received a Property Tax or Rent Rebate check in

sickness. Damages include Black Lung benefits and benefits

the past, but you received Social Security disability benefits

granted under Section 306(c) of the Workers Compensation

during 1999, you must send a copy of the document from the

Security Fund Act (relating to Schedule of Compensation for

Social Security Administration which shows that you qualified

disability from permanent injuries of certain classes)

for Social Security disability benefits during 1999.

Payments provided to eligible low-income household under

If you received Supplemental Security Income (SSI), perma-

the Commonwealth’s Low Income Home Energy Assistance

nent and total disability benefits, or Railroad Retirement per-

program

manent and total disability benefits, or Black Lung disability

Payments received by home providers of the domicil-

benefits during 1999, a copy of your award letter is sufficient

proof of your disability.

iary care program administered by the Department of Aging,

except those payments in excess of the actual expenses of the

If you received disability benefits under the Veterans

care

Administration program or the Federal Civil Service program,

you must request that the Veterans Administration or the Civil

Disability income received by disabled children in the

Service Commission release your medical records to the PA

household

Department of Revenue, Bureau of Individual Taxes, Dept.

Black Lung benefits

280503, Harrisburg, PA 17128-0503.

You must report on Lines 4 through 9 income such as:

If you applied for Social Security disability benefits, but the Social

Security Administration did not rule in your favor, you are not

Salaries

eligible for a Property Tax or Rent Rebate as a disabled claimant.

Wages

If you do not qualify under any of the disability programs men-

Bonuses

tioned above, you must submit a complete medical report

Commissions

from your family physician.

Value of an inheritance

PART C - TOTAL INCOME

Income from self-employment, including partnership and PA

Lines 4 through 10. You must report the income you earned and

S corporation income

received during 1999. You must also report the income your spouse

Alimony

earned and received while residing with you during 1999. Enter your

income, or the combined income of you and your spouse, for each

Support money

category. You must submit a copy of your federal or PA income tax

Cash public assistance and relief

return as evidence of the amounts you are reporting on your claim

The gross amount of pensions and annuities, includ-

form. If you do not have to file a federal tax return, submit copies of

your forms and other statements showing your income. The

ing total distributions from any Individual Retirement Account

Department may request evidence of your income.

50% of your 1999 Railroad Retirement Benefits Social

Example: You do not have to file a federal tax return, but you do file

Security Equivalent Benefits Portion of Tier 1

a PA tax return. You received Social Security benefits and

100% of your 1999 Annuity or Pension Benefits paid by the

pension income in 1999. Such income is not taxable on

Railroad Retirement Board

your PA tax return. You must submit a photocopy of your

50% of your 1999 gross Social Security Benefits

PA tax return and photocopies of your SSA and pension

statements.

50% of your 1999 Supplemental Security Income (SSI)

You must report all items of income, except those listed under DO

100% of your 1999 Medicare premiums

NOT REPORT, even if the income is not taxable for federal or PA

Unemployment compensation

income tax purposes.

Veterans’ disability payments

DO NOT REPORT:

All interest (including interest from federal, state and

local governmental obligations) and dividends

50% of your 1999 Railroad Retirement Benefits Social

Security Equivalent Benefits Portion of Tier 1

Rental and royalty income

Workers compensation benefits, except Section 306(c) benefits

50% of your 1999 gross Social Security Benefits

Gross amount of loss of time insurance benefits

50% of your 1999 Supplemental Security Income (SSI)

Life insurance benefits and proceeds (except the first

Medicare benefits

$5,000 of the total death benefit payments)

Form Pa-1000 - Instructions For Completing Your Claim Form - Property Tax Or Rent Rebate Program Page 2

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