STROUDSBURG AREA SCHOOL DISTRICT SENIOR CITIZEN PROPERTY TAX REBATE YEAR – 2009 COMPLETE STATE REBATE FORM FIRST (SEE INSTRUCTIONS ON BACK OF THIS FORM) PART A PLEASE PRINT OR TYPE Name of Claimant: Name of Spouse: Address of Claimant: Phone No.: Location of Property: (Borough or Township) Birthdate of Claimant: (Attach proof to first application) Birthdate of Spouse: Social Security Number of Claimant: SS# of Spouse: PART B - Please check only one of the following: ____ Claimant is age 65 or older ____ Claimant is under age 65 with a spouse age 65 or older who resided in the same household ____ Claimant is permanently disabled and age 18 to 64 PART C Enter amount from Line 12 of 2009 PA-1000 Property Tax or Rent Rebate (If your total income exceeds $20,000, you may not claim a rebate.) Enter amount of 2009 School District Property Taxes paid for Homestead Enter amount from Line 18 of 2009 PA-1000 Property Tax or Rent Rebate FOR OFFICE USE ONLY Lesser of maximum rebate determined by income level table or school taxes minus state rebate Table Income Level Maximum Rebate Amount $0 to $14,999 $500 $15,000 to $20,000 $250 IMPORTANT: A copy of your 2009 Form PA-1000 (State Rebate Form) must be attached, along with supporting documents listed on the back of this form. Excessive claims made with fraudulent intent will subject the claimant to a penalty of 25% of the entire amount claimed. The claimant shall be guilty of a misdemeanor punishable by a fine up to $1,000 and/or imprisonment up to 1 year upon conviction. ►I declare that this claim is true, correct, and complete to the best of my knowledge and belief, and that this is the only claim filed by members of my household. Claimant’s Signature Date Signature of Preparer- if other than claimant Date STROUDSBURG AREA SCHOOL DISTRICT 123 LINDEN STREET, STROUDSBURG, PA 18360 (570) 421-1990 INSTRUCTIONS FOR 2009 SENIOR CITIZENS PROPERTY TAX REBATE 1. COMPLETE PART A: If this is your first application, provide proof of birth date and social security number. (You can use your birth certificate, PA driver’s license, or PA identification card.) 2. COMPLETE PART B: If you’re under 65 and disabled and this is your first application, provide proof of your disability. (This can be a copy of your award letter from Social Security, or a letter from the VA or Federal Civil Service. If you have not been declared disabled by any of those agencies, provide a copy of your PA-1000 PS Physician’s Statement of Permanent Disability.) 3. COMPLETE PART C: Only the school taxes paid on the homestead residence in which you live are eligible for rebate. Include a copy of the receipt for those paid taxes. 4. We will calculate the allowable tax rebate. 5. WHEN TO FILE: After February 1, 2010, and before June 30, 2010. 6. WHERE TO FILE: Mail or bring your form to the district’s Business Office at 123 Linden Street 7. ATTACH TO THIS FORM: Attach the following documents, in order: a. Signed copy of your state rebate form (PA-1000 Pennsylvania Property Tax or Rent Rebate). b. Copy of your school tax receipt. c. Copy of the documents supporting each income item shown on the state rebate form. d. If this is your first application, copy of the proof of age or disability 8. If you need assistance in completing your form, you can contact the School District Business Office at 570-421-1990, or the Monroe County Area Agency on Aging at 570-420-3735.