Property Tax/rent/heat Rebate Booklet - 2012 (Page 6 of 8) in pdf

Property Tax/rent/heat Rebate Booklet - 2012 Page 6

DR 4679 PTC (08/23/12)

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COLORADO DEPARTMENT OF REVENUE

Denver CO 80261-0005

Affidavit — Restrictions on Public Benefits

PRIMARY APPLICANT

, swear or affirm under penalty of perjury

______________________________________________________________

under the laws of the State of Colorado that (check one):

I am a United States citizen.

I am not a United States citizen, but I am a Permanent Resident of the United States.

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.

________________________________________________________

SPOUSE, IF MARRIED

, swear or affirm under penalty of perjury

______________________________________________________________

under the laws of the State of Colorado that (check one):

I am a United States citizen.

I am not a United States citizen, but I am a Permanent Resident of the United States.

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.

________________________________________________________

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 §18-8-503, C.R.S. and it shall

constitute a separate criminal offense each time a public benefit is fraudulently received.

Primary Applicant Signature

Date

Spouse Signature

Date

Property Tax/rent/heat Rebate Booklet - 2012 Page 6