Fillable Printable Tc-90Cb - Utah State Tax Commission
Fillable Printable Tc-90Cb - Utah State Tax Commission
Tc-90Cb - Utah State Tax Commission
US
T
C
O
RI
G
INAL F
O
RM
You can complete this form in TAP at tap.tax.utah.gov/TaxExpress.
Check below
►
Section 1 - Applicant Information if widow(er)
NOTE: Only one application per address.
Applicant’s first name Applicant’s last name Birth date Deceased date SSN/Circuit Breaker acct. no.
(mm/dd/yyyy) (mm/dd/yyyy)
Spouse’s first name Spouse’s last name Birth date Deceased date SSN/Circuit Breaker acct. no.
(mm/dd/yyyy) (mm/dd/yyyy)
Street address City State ZIP Code Daytime telephone number
CHECK THIS BOX if you are a manufactured homeowner applying for a lot rental refund: •
► Section 2 - Do You Qualify For A Refund?
A. Were you age 66 or older on or before Dec 31 of last year? If you are under 66 years,. . . . A Yes No
are you an UNMARRIED widow/widower?
(Go to question B) (Don’t send form)
B. Did you financially support yourself last year and cannot be claimed as a dependent . . . • B Yes No
on someone else’s tax return?
(Go to question C) (Don’t send form)
C. Did you live in Utah all of last year?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • C Yes No
(Continue with form) (Don’t send form)
Annual Household Income
Total members in household with income last year — REQUIRED •
Complete lines 1–10 below. If more than one person received income, first use the
Household Income Worksheet (TC-90CB_W), and then enter the totals on lines 1–9 below.
ANNUAL amounts
1. Wages/salaries/tips/other compensations (W-2, 1099Misc, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 1 .00
2. Total interest income, dividends (taxable and nontaxable). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 2 .00
3. Pensions, annuities (taxable and nontaxable). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 3 .00
4. Gross Social Security and railroad retirement (taxable and nontaxable). . . . . . . . . . . . . . . . . . . . . . .
• 4 .00
5. Capital gain/loss (exclude carryforwards/carrybacks) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 5 .00
6. Government assistance given directly to you. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 6 .00
7. Unemployment, worker’s compensation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 7 .00
8. Business, rental, farm income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 8 .00
9. Other income (see Utah Code 59-2-1202) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• 9 .00
10. Total household income from all sources for last year (add lines 1 through 9). . . . . . . . . . . . . . . . . . .
• 10 .00
11. Maximum income amount.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
$32,101
If the amount on line 10 is greater than the amount on line 11, you do not qualify for a renter refund.
STOP
STOP
STOP
►
►
90511
Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-0800
Renter Refund Application
(Circuit Breaker Application)
TC-90CB
Rev. 1/17
9998
•
For rent year:
•
Due date: Dec. 31,
Clear form
2016
2017
US
T
C
O
RI
G
INAL F
O
RM
► Section 3 - Last Year’s Rent Information (see instructions)
List each place you rented last year. Enter the total months you lived at each address LAST YEAR ONLY.
Enter the total amount of rent YOU paid ONLY. If you received rental assistance, only enter the portion of rent YOU paid
out-of-pocket. Do NOT include other fees (such as cable, storage, parking, pet, cleaning, late payment, etc.).
#1 Rental address Landlord name Landlord phone no. • Months last • Total rent paid last year
year at address at this address
.00
• Check if gas is included in rent • Check if electricity is included in rent
#2 Rental address Landlord name Landlord phone no. • Months last • Total rent paid last year
year at address at this address
.00
• Check if gas is included in rent • Check if electricity is included in rent
#3 Rental address Landlord name Landlord phone no.
• Months last • Total rent paid last year
year at address at this address
.00
• Check if gas is included in rent • Check if electricity is included in rent
► Section 4 - Residency Status, Certification and Signature
Under state and federal law, we are prohibited from processing this application or issuing a credit to any person who fails
to provide residency status information.
Check ONE (providing false information subjects the signer to penalties for perjury):
• 1. I am a U.S. citizen.
• 2. I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully.
If you checked box 2, you must file this form in person and bring proof of your I-94 Number and/or Alien Registration Number.
• I-94 Number*: • Alien Registration Number*:
*The I-94 (arrival/departure) number and the Alien Registration Number are issued by the U.S. Citizenship and Immigration Service.
Under penalties of perjury, I declare to the best of my knowledge and understanding, all the information on this application is
true, correct and complete.
Complete and sign this application, then mail to:
UTAH STATE TAX COMMISSION Fax: 801-297-7574
210 N 1950 W Phone: 801-297-6254
SALT LAKE CITY, UT 84134
TC-90CB pg. 2
Signature of applicant Date Signature of spouse Date
Preparer’s name and address or organization (if applicable)
Preparer’s phone number
90512
A. You B. Your Spouse C. Other Person D. Other Person E. Other Person F. Totals
in Household #1 in Household #2 in Household #3
Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Social Security Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Wages/salaries/tips/other
compensation (W-2,
1099Misc., etc.)
2. Total interest income
and dividends (taxable
and nontaxable)
3. Pensions and annuities
(taxable and nontaxable)
4. Gross Social Security
& railroad retirment
(taxable and nontaxable)
5. Capital gain/loss
(exclude carryforwards/
carrybacks)
6. Government assistance
given directly to you
7. Unemployment,
worker’s compensation
8. Business, rental and
farm income
9. Other income (alimony,
nontaxable interest, etc.)
See Utah Code 59-2-1202
NOTE: If you entered numbers on lines 3, 5, 6, or 8, keep copies of federal returns and schedules with your records.
90513
Household Income Worksheet TC-90CB_W
t
Use this worksheet if you were not the only person in your household with income last year.
t
On each line, enter total ANNUAL amounts for the whole year.
t
For each line, add the amounts in columns A through E and enter the total in Column F.
t
Enter the totals from column F in Section 2 (Household Income) of the Renter Refund Application.
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
.00 .00 .00 .00 .00 .00
USTC ORIGINAL FOR
no
no
Se
Se
T
T
Renter Refund Application Instructions
Submit only ONE application per address.
Report total
ANNUAL amounts for income and rent — do NOT report monthly
amounts.
Section 1 – Applicant Information
• You must complete all fields.
• If you are a widow(er) age 66 or older, you do not need to
provide information about your deceased spouse.
• If you are an unmarried widow(er) under age 66, check the
widow(er) box and enter your spouse's name, birth date,
death date and SSN or account ID. A surviving spouse must
have been a member of the deceased spouse's household at
the time of their death, and be unmarried at the time the
claim is filed.
Section 2 – Do You Qualify For a Refund?
You must answer questions A - C.
Annual Household Income
•
Enter the total number of members in the household on
the first line of this section.
• Household income is ALL INCOME received from ALL
PERSONS living in the household last year, not just the
applicant. If the applicant is the only household member with
income, complete lines 1 - 9.
• If more than one household member received income, you
must complete the Household Income Worksheet. Take the
totals from column F of the worksheet and copy them to
Section 2, lines 1 - 9 of the application. Submit BOTH the
application AND the worksheet.
• Keep all federal returns and schedules with your records in
case of Tax Commission review.
Section 3 – Annual Rent Information
For each location entered, you must complete all fields. Keep
proof with your records showing how much rent was paid
(receipts, bank copies of cancelled checks, etc.).
Section 4 – Residency Status, Certification and Signature
• Enter your residency status. Check ONE box ONLY. If you
check box 2, you must file this form in person and show proof
of your I-94 and/or Alien Registration Number.
• To present proof of your I-94 or Alien Registration Number
please go to one of the following Tax Commission locations:
210 North 1950 West 2540 Washington Blvd., 6th Floor
Salt Lake City, Utah 84134 Ogden Regional Center
Ogden, Utah 84401
150 East Center #1300 100 South 5300 West
Provo, Utah 84606 Hurricane, Utah 84737
Sign the application. If a preparer completed this form on
your behalf, enter the preparer’s name, address and phone
number.
What To Attach
Send the following with your application (also keep a copy for
your records):
• TC-90CB, pages one and two.
• TC-90CB Schedule W if more than one household member
received income.
What To Keep
• Your federal returns and schedules.
• All other supporting documentation, including proof of income
and rent paid.
We will review and determine eligibility for refund. You may be
required to submit more information to support your claims.
NOTE: Your refund may be delayed and/or reduced if you
enter monthly figures for income or rent.
If you are a homeowner or manufactured homeowner
applying for a property tax credit, you must file form TC-90CY
with the county where the property is located by Sept 1 of this
year. Contact your local county agency for more information.
See Pub 36 for more information about property tax relief. Get
Pub 36 online at tax.utah.gov/forms/pubs/pub-36.pdf.
For More Information Contact:
Utah State Tax Commission
801-297-6254, or
1-800-662-4335 ext. 6254
Davis County Aging Services
801-525-5050
Salt Lake County Aging Services
385-468-3200
Utah County Aging Services
801-229-3800
Washington County Aging Services
435-634-5712
Also visit us online at tax.utah.gov
Renter Refund Schedule
2016 Household Income Limits
Renter Refund Maximum
Lower Upper
% of rent Renter Refund
$0 $10,913 9.5% $951
10,914 14,553 8.5% 829
14,554 18,190 7.0% 711
18,191 21,828 5.5% 533
21,829 25,468 4.0% 415
25,469 28,890 3.0% 237
28,891 32,101 2.5% 117
Renter Refund Application TC-90CB
instructions
