Free TC-40cb, Renter Refund Application - Utah

Clear form

Utah State Tax Commission

Renter Refund Application
(Circuit Breaker Application)

2009
TC-40CB
Rev. 5/09

Return this application to Taxpayer Services Division Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800

Renters and Mobile Homeowners applying for lot rental refund, file this application with the Utah State Tax Commission by December 31, 2009. Homeowners and Mobile Homeowners applying for property tax credit, must file TC-40CY with the county where the property is located.

Applicant's Name If more than one person lives in a household, only one person can file an application.
Applicant's Last Name Applicant's First Name Middle Initial Birth Date Social Security Number

Spouse's Last Name (if spouse is living)

Spouse's First Name

Middle Initial

Birth Date

Social Security Number

Address

City

County

State

ZIP Code

Daytime Telephone Number

Do You Qualify For A Refund?
APPLICANT must answer questions 1 through 5. 1. Were you age 65 or older on or before December 31, 2008, OR are you a widow or widower? Enter spouse's date of death: _____________. Attach a copy of your deceased spouse's death certificate if this is the first year you are claiming a refund as a widow or widower. Total members in household as of Jan. 1, 2008 2. 2008 Household Income (from all household members living in the household as of January 1, 2008, not just applicant).
A. Wages/salaries/tips/other compen. B. Total interest, dividends (taxable/nontaxable) C. Pensions, annuities (incl. IRAs) D. Soc. Sec./Railroad retirement (taxable/nontaxable) E. Capital gains, loss carry forwards F. Government assistance G. Unemployment, worker's comp. H. Business, rental, farm income I. Other income (alimony, etc.) A B C D E F G H I J. Total 2008 household income from J all sources (add lines A through I) Are you eligible to claim a dependent as a personal exemption on your 2008 federal income tax return?
No (enter total 2008 household income from line J to line K) Yes (subtract $1,000 from line J and enter result on line K)

Yes
(Go on to question 2)

No
(STOP, you do NOT qualify)

K. Adjusted 2008 household income

K

Is the amount in line K above less than or equal to $28,732? Household Income is income received during 2008 by all members of a household (not just the applicant) living in the same dwelling, sharing furnishings, facilities, accommodations and expenses as of Jan. 1, 2008. 3. Did you furnish your own financial support for 2008 and cannot be claimed as a dependent on someone else's tax return? 4. Did you live in Utah for the entire year of 2008? You must have lived in Utah for the entire calendar year to be eligible. 5. Are you a mobile homeowner applying for a lot rental refund?

Yes
(Go on to question 3)

No
(STOP, you do NOT qualify)

Yes
(Go on to question 4)

No
(STOP, you do NOT qualify)

Yes
(Go on to question 5)

No
(STOP, you do NOT qualify)

Yes

No

Clear form
Section One - Rent Information
Complete this section for each place you rented during 2008. If you received rental assistance, you can only claim the portion of rent you paid.
Address of apartment or mobile/home lot (include apartment or lot number) Name and telephone number of landlord or manager Date rented in 2008 from - to Total months Monthly rent you paid Total rent you paid

Utilities included in rent?

None

Gas

Electric

Utilities included in rent?

None

Gas

Electric

Utilities included in rent?

None

Gas

Electric

Utilities included in rent?

None

Gas

Electric

Total rent you paid in 2008 (This amount should not include the cost of utilities)

Section Two - Residency Status of Applicant
Under state and federal law we are prohibited from processing this application or issuing a credit to any person who fails to provide this information. The Alien Registration Number and the I-94 numbers are issued by the U.S. Citizenship and Immigration Service.

Check one: I am a U.S. citizen. SSN: ________________ I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully. I-94 #:________________ Alien #:_______________

Section Three - Certification and Signature

Certify, sign and date.

Under penalties of perjury, I declare to the best of my knowledge and understanding, this information is true, correct and complete.
Signature of applicant Date Signature of spouse Date Preparer's telephone number

X
Preparer's name and address or organization (if not applicant)

X

Return this application to Taxpayer Services Division, Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800

Renter Refund Schedule
2008 Household Income Limits Renter Refund % of rent Lower Upper $0 9,769 13,027 16,282 19,538 22,796 25,859 $9,768 13,026 16,281 19,537 22,795 25,858 28,732 9.5% 8.5% 7.0% 5.5% 4.0% 3.0% 2.5%
Maximum Renter Refund

For More Information Contact: Golden Years Center (Bountiful) 801-295-3479 Salt Lake County Division of Aging 801-468-2480 Heritage Center (Clearfield) 801-773-7065 Davis County Aging Services 801-451-3377 Autumn Glows Center (Kaysville) 801-451-3329 Utah State Tax Commission 801-297-2200 or outside Salt Lake area, 1-800-662-4335 or on the web at tax.utah.gov

$851 742 637 477 371 212 105