please help to fill out the form below. Thanks.

SOCIAL SECURITY Directions: Use the following information to complete (by hand) the CO 104 PTC Rebate on the following pages. Taxpayer Tom Jones is 73 years old, single, and lives alone. He comes into the tax site with the following information: Tom is a US citizen and resident of Co His DOB is 104/1946 His physical and mailing address is: 316 Josephine Ave, Apt 3C, Denver, CO 80206 Hi phone number is 720-252-3189 He cannot be claimed as a dependent Tom was single for all of 2019 Tom has no dependents Driver's License number is 99-939-9999. Expiration date: 01/01/2021 Recelved Medicare for the entire year and premiums were paid by Medicaid. During 2019 he received the following sources of income: $750 per month from social security benefits for the entire year Tom works part time for the local church, until he fell ill in September See W2 below Expenses for the year o $375 per month for rent (meals and heat are not included and the rent was not for a property tax exempt unit) o $25 per month for heat He prefers a check in the mail. SECUA ECIAL 714-XX-XXXX Tom Jones 22222 a Employee's social security number 714-XX-XXXX b Employer identification number (EIN) 98-1234747 o Employer's name, address, and ZIP code MOUNT HOLY CROSS CHURCH 231 RED CLIFF RD EAGLE 81631 OMB No. 1545-0008 1 Wages, tips, other compensation 2 Federal income tax withhold $2,000.00 $0.00 3 SOGIN security wages 4 Social Security tax withold $2,000.00 $124.00 5 Medicare wings and tips 6 Medicare lax withhold $2,000.00 $29.00 7 Social security tips 8 Allocated Tips 9 10 Dependent care benefits d Control number 12a Sul, 11 Nonqualified plans Last name 13 The 120 Employee's first name and initial TOM JONES 316 JOSEPHINE AVE. DENVER 80206 14 Other 120 2d FO 18 Locages, tips, 19 Local como la + Employee's address and ZIP code Employer's state ID number 91-8323323 16 State Wages, tips, etc. 17 State income tax $2,000.00 Department of the Treasury-Www Reverse Service Wage and Tax Form Statement Copy 1 -For State, City, or Local Tax Department W-2 20TY DR DIPTC (1007/19 COLORADO DEPARTMENT OF REVENUE Denver CO 80261-OODS Colorado por 190104PT19999 (1063) 2019 Colorado Property Tax/Rent/Heat Rebate Application Mart here this application is being fled to correct a previously filed 2010 PTC application Last Name yoursel First Name Middle Initial Deceased Date of Birth SSN Yes Colorado Driver License Number Expiration Date M.COM Last Narne spouse. married First Name Middle initial Deceased Date of Birth MW SSN Yes Spouse Driver License ID Number Expiration Date MBTW Physical Address Phone Number State ZIP Maling Address Charent from yol address Email Address Star you did not live bedress listed above for all of 2010, you must attach a list of addresses at which you ived during 2010 and the dates you lived each location Check the first box that applies to you or your spouse partner. If none apply do not let this form because you do not qualify for this rebate B. Age 65 or older on December 31, 2019 A widow or widower at least 58 years of age on December 31, 2019 Totally disabled for all of 2019 and received payment of full benefits from Social Security, SSI or the Department of Human Services based solely on such disability Totally disabled for all of 2019 and received payment of full benefits from a bona fide public or private plan of source based solely on such disability. You MUST attach proof of disability (see page 4 of the instruction book for examples of proof 3 15 190104PT29999 DR 0104PTC (1019) COLORADO DEPARTMENT OF REVENUE Denver CO 80261-0005 Colorado powTax Account Number Name List in the boxes below the TOTAL amount(s) received January through December 2019. If joint, add together the income for both parties before listing the total. DO NOT enter your monthly amounts. 1. Enter the number of months (1-12) you received Medicare during 2019. If your Medicare premiums were paid by Medicaid enter 0. .1 2. Social Security SSI and/or A.N.D. benefits 2 00 3. Colorado Old Age Pension 3 00 4. Private or VA pension payments received 100 5. Wages salaries and tips .5 00 6. Interest and dividends 00 7. Other income Explain Enter your property tax rent and heat expenses .7 00 bo .9 00 .10 100 8. If you paid 2018 property tax in 2019 enter amount here. 9. If you paid rent, enter the total for the year here. 10. If you paid heat or fuel expenses, enter the total for the year here 11. Are your meals included in your rent payments? NO Yes OR Only part of the year, enter amount 12. Was your heat included in your rent payments? No Yes OR Only part of the year, enter amount 11 100 12 00 Rang Member Checking Savings Direct Deposit ut urter declare under penal penyin the second degree that the best of my knowledge and belief the information herein is true correct and completa Furore, or the Department of Rere to contact the appropriate agencies to verify my information provided on this form and the agences are hereby hand se wuch information to the Department of Revenge TOMCOM Mail to Colorado Department of Revenue, Denver, CO 80251.0005 IMPORTANT-You must also complete and sign the atidavit on the next page. 4 15 190104PT39999 TELOR 70 - Affidavit - Restrictions on Public Benefits IMPORTANT- Do not forget to sign and attach this form with your application. Yourself 1 the State of Colorado that (check one) swear or affirm under penalty of perjury under the laws of . 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 AB joint, spouse or partner swear or affirm under penalty of perjury under the laws of 1. the State of Colorado that check one) .1. I am a United States citizen, 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. we not a United States citiren, enter your Alien Registration Number AB I understand that this swom statement is required by law because I have applied for a public benet. 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 further acknowledge that making a false, fictitious, or fraudulent statement or representation in this worn 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 in fraudulently received 5 5 SOCIAL SECURITY Directions: Use the following information to complete (by hand) the CO 104 PTC Rebate on the following pages. Taxpayer Tom Jones is 73 years old, single, and lives alone. He comes into the tax site with the following information: Tom is a US citizen and resident of Co His DOB is 104/1946 His physical and mailing address is: 316 Josephine Ave, Apt 3C, Denver, CO 80206 Hi phone number is 720-252-3189 He cannot be claimed as a dependent Tom was single for all of 2019 Tom has no dependents Driver's License number is 99-939-9999. Expiration date: 01/01/2021 Recelved Medicare for the entire year and premiums were paid by Medicaid. During 2019 he received the following sources of income: $750 per month from social security benefits for the entire year Tom works part time for the local church, until he fell ill in September See W2 below Expenses for the year o $375 per month for rent (meals and heat are not included and the rent was not for a property tax exempt unit) o $25 per month for heat He prefers a check in the mail. SECUA ECIAL 714-XX-XXXX Tom Jones 22222 a Employee's social security number 714-XX-XXXX b Employer identification number (EIN) 98-1234747 o Employer's name, address, and ZIP code MOUNT HOLY CROSS CHURCH 231 RED CLIFF RD EAGLE 81631 OMB No. 1545-0008 1 Wages, tips, other compensation 2 Federal income tax withhold $2,000.00 $0.00 3 SOGIN security wages 4 Social Security tax withold $2,000.00 $124.00 5 Medicare wings and tips 6 Medicare lax withhold $2,000.00 $29.00 7 Social security tips 8 Allocated Tips 9 10 Dependent care benefits d Control number 12a Sul, 11 Nonqualified plans Last name 13 The 120 Employee's first name and initial TOM JONES 316 JOSEPHINE AVE. DENVER 80206 14 Other 120 2d FO 18 Locages, tips, 19 Local como la + Employee's address and ZIP code Employer's state ID number 91-8323323 16 State Wages, tips, etc. 17 State income tax $2,000.00 Department of the Treasury-Www Reverse Service Wage and Tax Form Statement Copy 1 -For State, City, or Local Tax Department W-2 20TY DR DIPTC (1007/19 COLORADO DEPARTMENT OF REVENUE Denver CO 80261-OODS Colorado por 190104PT19999 (1063) 2019 Colorado Property Tax/Rent/Heat Rebate Application Mart here this application is being fled to correct a previously filed 2010 PTC application Last Name yoursel First Name Middle Initial Deceased Date of Birth SSN Yes Colorado Driver License Number Expiration Date M.COM Last Narne spouse. married First Name Middle initial Deceased Date of Birth MW SSN Yes Spouse Driver License ID Number Expiration Date MBTW Physical Address Phone Number State ZIP Maling Address Charent from yol address Email Address Star you did not live bedress listed above for all of 2010, you must attach a list of addresses at which you ived during 2010 and the dates you lived each location Check the first box that applies to you or your spouse partner. If none apply do not let this form because you do not qualify for this rebate B. Age 65 or older on December 31, 2019 A widow or widower at least 58 years of age on December 31, 2019 Totally disabled for all of 2019 and received payment of full benefits from Social Security, SSI or the Department of Human Services based solely on such disability Totally disabled for all of 2019 and received payment of full benefits from a bona fide public or private plan of source based solely on such disability. You MUST attach proof of disability (see page 4 of the instruction book for examples of proof 3 15 190104PT29999 DR 0104PTC (1019) COLORADO DEPARTMENT OF REVENUE Denver CO 80261-0005 Colorado powTax Account Number Name List in the boxes below the TOTAL amount(s) received January through December 2019. If joint, add together the income for both parties before listing the total. DO NOT enter your monthly amounts. 1. Enter the number of months (1-12) you received Medicare during 2019. If your Medicare premiums were paid by Medicaid enter 0. .1 2. Social Security SSI and/or A.N.D. benefits 2 00 3. Colorado Old Age Pension 3 00 4. Private or VA pension payments received 100 5. Wages salaries and tips .5 00 6. Interest and dividends 00 7. Other income Explain Enter your property tax rent and heat expenses .7 00 bo .9 00 .10 100 8. If you paid 2018 property tax in 2019 enter amount here. 9. If you paid rent, enter the total for the year here. 10. If you paid heat or fuel expenses, enter the total for the year here 11. Are your meals included in your rent payments? NO Yes OR Only part of the year, enter amount 12. Was your heat included in your rent payments? No Yes OR Only part of the year, enter amount 11 100 12 00 Rang Member Checking Savings Direct Deposit ut urter declare under penal penyin the second degree that the best of my knowledge and belief the information herein is true correct and completa Furore, or the Department of Rere to contact the appropriate agencies to verify my information provided on this form and the agences are hereby hand se wuch information to the Department of Revenge TOMCOM Mail to Colorado Department of Revenue, Denver, CO 80251.0005 IMPORTANT-You must also complete and sign the atidavit on the next page. 4 15 190104PT39999 TELOR 70 - Affidavit - Restrictions on Public Benefits IMPORTANT- Do not forget to sign and attach this form with your application. Yourself 1 the State of Colorado that (check one) swear or affirm under penalty of perjury under the laws of . 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 AB joint, spouse or partner swear or affirm under penalty of perjury under the laws of 1. the State of Colorado that check one) .1. I am a United States citizen, 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. we not a United States citiren, enter your Alien Registration Number AB I understand that this swom statement is required by law because I have applied for a public benet. 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 further acknowledge that making a false, fictitious, or fraudulent statement or representation in this worn 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 in fraudulently received 5 5