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SENIOR CITIZEN PROPERTY TAX REBATE - PDF - PDF

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					                                    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.

				
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