Form Dr 4679 Ptc - Affidavit - Restrictions On Public Benefits

ADVERTISEMENT

DR 4679 PTC (08/03/09)
COLORADO DEPARTMENT OF REVENUE
AFFIDAVIT - RESTRICTIONS ON PUBLIC BENEFITS
PRIMARY APPLICANT
I,
, swear or affirm under penalty of perjury
______________________________________________________________
under the laws of the State of Colorado that (check one):
1.
I am a United States citizen.
2.
I am not a United States citizen, but I am a Permanent Resident of the United States.
3.
I am not a United States citizen, but I am lawfully present in the United States pursuant to Federal law.
If you are not a United States citizen, enter your Alien Registration Number.
A#
________________________________________________________
SPOUSE, IF MARRIED
I,
, swear or affirm under penalty of perjury
______________________________________________________________
under the laws of the State of Colorado that (check one):
1.
I am a United States citizen.
2.
I am not a United States citizen, but I am a Permanent Resident of the United States.
3.
I am not a United States citizen, but I am lawfully present in the United States pursuant to Federal law.
If you are not a United States citizen, enter your Alien Registration Number.
A#
________________________________________________________
I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that
state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit.
I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit
is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute
18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
Primary Applicant Signature
Date
Spouse Signature
Date
104PTC Booklet Page 4

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit)- 2012 Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit)- 2012 Financial
Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2009 Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2009 Financial
Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2010 Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2010 Financial
Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2011 Form Dr 104 Ptc - Property Tax/rent/heat Rebate Application/dr 4679 Ptc - Affidavit - 2011 Financial
Form Dr 4678 - Request For Waiver - Restrictions On Public Benefits Form Dr 4678 - Request For Waiver - Restrictions On Public Benefits Financial
Form Dr 104 Ptc Draft - Property Tax/rent/heat Rebate Application/dr 4679 Ptc Draft - Affidavit - 2010 Form Dr 104 Ptc Draft - Property Tax/rent/heat Rebate Application/dr 4679 Ptc Draft - Affidavit - 2010 Financial
Form 6734 - 1984 - Waiver Of Restrictions On Assessment And Collection Of Deficiency In Tax And Acceptance Of Overassessment - Windfall Profit Tax - Department Of Tresuary - Internal Revenue Service Form 6734 - 1984 - Waiver Of Restrictions On Assessment And Collection Of Deficiency In Tax And Acceptance Of Overassessment - Windfall Profit Tax - Department Of Tresuary - Internal Revenue Service Financial
Form 5838 - 1980 - Waiver Of Restrictions On Assessment And Collection Of Tax Return Preparer Penalty - Department Of The Treasure Form 5838 - 1980 - Waiver Of Restrictions On Assessment And Collection Of Tax Return Preparer Penalty - Department Of The Treasure Financial
Form 870 S - Waiver Of Restrictions On Assessment And Collection Of Deficiency In Tax And Acceptance Of Overassessment Form 870 S - Waiver Of Restrictions On Assessment And Collection Of Deficiency In Tax And Acceptance Of Overassessment Financial
Form 870-e - Waiver Of Restrictions On Assessment And Collection Of Deficience And Acceptance Of Overassessment Form 870-e - Waiver Of Restrictions On Assessment And Collection Of Deficience And Acceptance Of Overassessment Financial

Related Categories

Parent category: Financial
Download
Go