Form Pr-141, Schedule Hi-144 - Renter Rebate Claim - 2017 Page 3

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*171441200*

Claimant’s Last Name

Social Security Number

* 1 7 1 4 4 1 2 0 0 *

1. Claimant and jointly

2. Filing separately

3. Other Persons

filed spouse

Spouse or CU Partner

1. Amount from Line n, Column 1

2. Amount from Line n, Column 2

3. Amount from Line n, Column 3

o. See instructions Enter Social Security and Medicare

tax withheld on wages claimed on Line d . Self-Employed:

Enter self-employment tax from Federal Schedule SE .

This entry may differ from W-2/1099 or Federal

Schedule SE amount if these taxes are paid on

income not required to be reported on Schedule

HI-144 . Include W-2 and/or Federal Schedule SE

.0 0

if not included with income tax filing . . . . . . . . . .o. ________________________

________________________

p. Child support paid . You must include proof

.0 0

of payment . See instructions . . . . . . . . . . . . . . . . p. ________________________

________________________

Support paid to: Last Name

First Name

Initial

Social Security Number

q. Allowable adjustments from Federal Form 1040 or 1040A

q1. Business Expenses for Reservists

.0 0

(1040, Line 24) . . . . . . . . . . . . . . . . . . q1. ________________________

________________________

.0 0

q2. Alimony paid (1040, Line 31a) . . . . . . q2. ________________________

________________________

q3. Tuition and fees (1040, Line 34 or

.0 0

1040A, Line 19) . . . . . . . . . . . . . . . . . q3. ________________________

________________________

q4. Self-employed health insurance

.0 0

deduction (1040, Line 29) . . . . . . . . . . q4. ________________________

________________________

q5. Health Savings Account deduction

.0 0

(1040, Line 25) . . . . . . . . . . . . . . . . . . q5. ________________________

________________________

r. Add Lines o, p and total of Lines q1 to q5 for

.0 0

each column . . . . . . . . . . . . . . . . . . . . . . . . . . . . .r. ________________________

________________________

s. Subtract Line r from Line n of each column .

.0 0

If a negative amount, enter -0- . . . . . . . . . . . . . . . s. ________________________

________________________

.0 0

t. Add all three amounts from Line s . If a negative amount, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . t. ________________________

u. Complete if born Jan . 1, 1953, and after .

Enter interest and dividend income from

.0 0

Lines e and f . . . . . . . . . . . . . . . . . . . . . . . . . . . . u. ________________________

________________________

.0 0

v. Add all three amounts from Line u . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v. ________________________

10000.0 0

w. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w. ________________________

.0 0

x. Subtract Line w from Line v . If Line w is more than Line v, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x. ________________________

.0 0

HOUSEHOLD INCOME.

Add Line t and Line x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . y. ________________________

RENTERS:

If Line y Household Income is $47,000 or less, you may be eligible for a renter rebate . Complete Form PR-141 . This schedule must

be filed with the Renter Rebate Claim . Claims are due April 17, 2018, but can be filed up to Oct . 15, 2018 .

If Household Income is more than $47,000, you do not qualify for a renter rebate .

HOMEOWNERS:

Form HS-122 , Property Tax Adjustment Claim, must be filed each year .

Homeowners with Household Income up to $147,500 on Line y should complete Form HS-122, Section B. You may be eligible for

a property tax adjustment . This schedule must be filed with the HS-122 .

Form HS-122 Due Date - April 17, 2018. Homeowners filing a property tax adjustment, Forms HS-122 and HI-144, between

April 18 and Oct . 15, 2018, may still qualify for a property tax adjustment . A $15 late filing fee will be deducted from the adjustment .

5454

Schedule HI-144, page 2 of 2