Fillable 2021 Colorado Property Tax/Rent/Heat Rebate Application (Colorado DORA)

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2021 Colorado Property Tax/Rent/Heat Rebate Application (Colorado DORA)

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The 2021 Colorado Property Tax/Rent/Heat Rebate Application (Colorado DORA) form is 2 pages long and contains:

  • 0 signatures
  • 3 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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*210104PT19999*
DR 0104PTC (10/25/21)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0005
Page 1 of 2
(1063)
2021 Colorado Property Tax/Rent/Heat Rebate Application
Mark here if this application is being led to correct a previously led 2021 PTC application.
Last Name (yourself) First Name Middle Initial
Deceased Date of Birth (MM/DD/YYYY) SSN or ITIN
Yes
Colorado Driver License/ID Number Expiration Date (MM/DD/YYYY) Alternate ID
Last Name (spouse, if married) First Name Middle Initial
Deceased Date of Birth (MM/DD/YYYY) SSN or ITIN
Yes
Spouse's Driver License/ID Number Expiration Date (MM/DD/YYYY) Alternate ID
Physical Address Phone Number
City State ZIP
Mailing Address (if different from physical address) Email Address
City State ZIP
If you did not live at the address listed above for all of 2021, you must include a list of addresses at which you lived
during 2021 and the dates you lived at each location.
Check the rst box that applies to you or your spouse/partner. If none apply, do not ll out this form because you do not qualify for this rebate.
A Age 65 or older on December 31, 2021.
B A widow or widower at least 58 years of age on December 31, 2021.
C
Totally disabled for all of 2021 and received payment of full benets from Social Security, SSI or the
Department of Human Services based solely on such disability.
D
Totally disabled for all of 2021 and received payment of full benets from a bona de public or private plan
or source based solely on such disability. You MUST include proof of disability (see page 4 of the instruction
book for examples of proof).
*210104PT29999*
DR 0104PTC (10/25/21)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0005
Page 2 of 2
Name Account Number
List in the boxes below the TOTAL amount(s) received January through December 2021. 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 2021. If your
Medicare premiums were paid by Medicaid, enter 0.
1
2.
Social Security, SSI and/or A.N.D. benets
2
00
3.
Colorado Old Age Pension
3
00
4.
Private or VA pension payments received 4
00
5.
Wages, salaries and tips 5
00
6.
Interest and dividends 6
00
7.
Other income, Explain 7
00
Enter your property tax, rent and heat expenses.
8.
If you paid 2020 property tax in 2021, enter amount here. 8
00
9.
If you paid rent, enter the total for the year here. 9
00
10.
If you paid heat or fuel expenses, enter the total for the year here. 10
00
11.
Are your meals included in your rent payments?
No Yes OR
Only part of the year, enter amount
11
00
12.
Was your heat included in your rent payments?
No Yes OR
Only part of the year, enter amount
12
00
13.
STATE SALES TAX REFUND
If you qualify, your state sales tax refund will be $37 if you are single, or $74 if you le jointly.
Direct
Deposit
Routing Number
Type: Checking Savings
Account Number
I declare under penalty of perjury in the second degree that to the best of my knowledge and belief the information herein is true, correct and complete.
Furthermore, I authorize the Department of Revenue to contact the appropriate agencies to verify any information provided on this form and the
agencies are hereby authorized to release such information to the Department of Revenue.
Your Signature Date (MM/DD/YY)
Mail to: Colorado Department of Revenue,
Denver, CO 80261-0005
Spouse/Partner Signature Date (MM/DD/YY) Prepared by
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2021 Colorado Property TaxRentHeat Rebate Application (Colorado DORA)

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Completed 13 February 2022

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