Property Tax/rent/heat Rebate Booklet - 2012 (Page 3 of 8) in pdf

Instructions

See publication FYI General 2 for Privacy Act Notice and General 7 for more information about PTC. Enter information for

the 2012 calendar year only. Mixing up information from other years will delay or deny your application.

• Physical address — If you did not live at this address for the full year, attach a list of all the places you lived throughout

this year. Be sure to include the dates you lived at each location.

• Mailing address — Be certain this is your current mailing address, otherwise you may not receive your rebate.

• Driver’s license or ID number and expiration date — All information on your license or ID card must exactly match

the information you have entered on your application, including your address. Update your address with the DMV

before applying if needed. Visit for more information.

• Email address, if you have one.

• Confirm your eligibility by checking the appropriate box. Check only one box. If you check box D, attach a copy of

your disability statement that is less than 90 days old. The statement must be provided by the agency that pays the

benefits. Veterans Administration Award letters must show the disability percentage at 50% or more.

• First-time filers must provide proof of full-year Colorado residency. If you did not hold your Colorado driver’s license

or ID card from January 1–December 31, 2012, you must attach a copy of your lease or rental agreement.

Income

Medicare: Enter the number of months (1–12) you were covered by Medicare. If your premiums were paid by

Line 1

Medicaid or if you were not on Medicare, enter 0.

Lines 2-6 Income: Enter the gross income you received for each item listed. Do not list only the taxable portion. The gross

amount should be clearly identified on the statement(s) you received from the payor. Do not include Medicare

benefits on line 2 if they were paid on your behalf by a third party.

Other Income: Review the tables below, and report any income you received from these sources that are not

Line 7

already included on lines 2–6.

YOU MUST REPORT THIS INCOME:

All Taxable Income

Disability Payments

Disability Insurance Settlements

Alimony

Inheritance

Lottery and Gambling Winnings

Worker’s Compensation

Life Insurance Distributions (exclude funeral expenses)

Commissions

Rental Income or Loss (exclude expenses, but not depreciation)

Royalties

Farm Income or Loss (exclude expenses, but not depreciation)

Veterans Benefits

AFDC or TANF Received (exclude payments received for dependents)

Capital Gains

Stock Dividends or Rights (only if reported on federal income tax return)

Tier 1 & 2 Railroad Retirement

Old Age Pension (OAP)

DO NOT REPORT THIS INCOME:

Child Support Received

Welfare Payments Received for Dependent Children (AFDC, etc.)

Gifts

Home Care Allowances or Adult Foster Care Assistance

Colorado PTC Rebates Received

Capital Losses or Return of Capital

Heat/Fuel Assistance such as LEAP

Income Tax Refunds

Veterans Service-connected Disability (permanent)

Expenses

Property Tax: Enter the total amount of property tax paid, if any. DO NOT include any supplement/assistance that

Line 8

was paid by the Senior Homestead Exemption. Include only taxes that you paid in the calendar year 2012.

Rent: Enter the total rent you paid January 1–December 31, 2012, if any.

Line 9

Heat/Fuel: Enter the total heat/fuel expenses you paid to heat your home during 2012, if any. DO NOT include

Line 10

any heat/fuel expenses that were included in your rent payment.

Meals: Check the appropriate box to indicate whether your meals were included in your rent. If meals were

Line 11

included for only part of the time you paid rent, enter how much rent was paid when your meals were included.

Property Tax Exempt: Check the appropriate box to indicate whether you lived in a property tax exempt home.

Line 12

If your home was property tax exempt for only part of the year, enter how much rent was paid when your home

was property tax exempt.

Heat/Fuel: Check the appropriate box to indicate whether your heat/fuel was included in your rent. If heat/fuel was

Line 13

included for only part of the time you paid rent, enter how much rent was paid when your heat/fuel was included.

104PTC Booklet Page 3

Property Tax/rent/heat Rebate Booklet - 2012 Page 3

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