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IOWA
2012 Iowa Special Assessment Credit
This claim must be filed or mailed to your county treasurer by September 30, 2012.
Iowa treasurers’ addresses can be found at the Iowa Treasurers Association Web site.
Claimant’s Last Name
First Name
Claimant’s Social Security Number
Claimant’s Birth Date
County
Number
/
/
/
/
Spouse’s Last Name
First Name
Spouse’s Social Security Number
Month
Day
Year
___
___
/
/
Street Address
City, State, ZIP
Do not write in this space.
YES
NO
Were you 65 or older, or totally disabled and 18 or older, as of December 31, 2011? ..................
If less than 65 and totally disabled, you must provide proof of your disability from
your doctor or Social Security office describing your disability and the date it began.
2011 Household Income (Claimant and Spouse)
Use Whole DOLLARS Only
0 0
,
1. Wages, salaries, unemployment compensation, tips, etc. _____________
.
,
0 0
2. In-kind assistance for housing expenses. __________________________
.
,
0 0
3. Title 19 benefits (excluding medical benefits). ______________________
.
,
0 0
4. Social Security income. ________________________________________
.
,
0 0
5. Disability income. ____________________________________________
.
,
0 0
6. All pensions and annuities. _____________________________________
.
,
0 0
7. Interest and dividend income. ___________________________________
.
8. Profits from businesses and / or farming and capital gain.
,
0 0
If less than zero, enter 0. See instructions. _________________________
.
,
0 0
9. Money received from others living with you. See instructions. __________
.
,
0 0
10. Other income. Read instructions before making this entry. ____________
.
0 0
,
11. Add lines 1-10. ______________________________________________
.
0 0
,
12. Medical and care expenses. See instructions. ______________________
.
,
0 0
13. SUBTRACT line 12 from line 11 and enter here. ____________________
.
(If more than $10,770, no credit is allowed.) This is your total household income.
Do not enter an amount on line 12 unless you are totally disabled and
For Use By
County Treasurer Only
incurred medical or care expenses attributable to your disability. List below
Installment
the nature and amount of each expense included on line 12.
Number: __________________
_____________________________________________________________
Annual Special
Assessment
_____________________________________________________________
Payment: __________________
_____________________________________________________________
State
Reimbursement: ____________
I declare under penalty of perjury that I have reviewed this claim and to the
best of my knowledge and belief, it is true, correct, and complete.
________________________________________
_________
( ____ ) ________________________
Claimant’s Signature
Date
Claimant’s Telephone Number
54-036a (09/21/11)