BENSALEM TOWNSHIP SCHOOL DISTRICT BENSALEM, PA 19020-1898 General Instructions Attached is an application for senior citizen property tax assistance. Persons who complete these applications should note the following: 1. Property tax assistance applies only to living senior citizens sixty-five (65) years of age or over whose legal and permanent residence is the residence for which tax assistance is sought. 2. If you apply for and receive a Homestead Exclusion or similar rebate related to another property, YOU ARE NOT ELIGIBLE FOR THIS REBATE. 3. Only one claimant (person filing the claim sixty-five years of age or over) shall be entitled to property tax assistance. If two or more persons in one homestead are able to meet the qualification as a claimant, they may determine who the claimant shall be. If they are unable to agree, the school district shall determine to whom assistance is to be paid. 4. It is not necessary that the school real estate tax be paid by the claimant, provided the tax is paid prior to filing the claim. 5. Each application should include reasonable proof of household income, a copy of the receipted school real estate tax bill, and proof that the claimant was age sixtyfive years or over during the 2013 calendar year. 6. An application filed with fraudulent intent, will be disallowed in full and a penalty of twenty-five percent (25%) of the amount claimed shall be imposed. The penalty and the amount of the disallowed claim will bear interest at the rate of one-half of one percent per month from the date of the claim until repaid. The claimant and any person assisting in the preparation or filing of a fraudulent claim shall be guilty of a misdemeanor and upon conviction thereof shall be sentenced to pay a fine not exceeding one thousand dollars ($1,000.00) or undergo imprisonment not exceeding one year, or both. 7. A claim shall be disallowed if the claimant received title to the property primarily for the purpose of receiving property tax assistance. 8. For additional information call 215-750-2800, Extension 4200. 9. This claim must be filed by June 30, 2014 for taxes due and paid in 2013. Mail to: Bensalem Township School District 3000 Donallen Drive Bensalem, PA 19020 Attention: Business Department
Part A -- Claimant's Identification Please complete in full (lines 1 through 11). SPECIFIC INSTRUCTIONS Part B -- Amount of 2013 Property Tax Paid and State Rebate Received In 2013. Enter the total amount of paid 2013 school property tax on line 12. No credit for interest or penalty payments may be used. Municipal assessments, per capita and occupation taxes must not be included in your computation of real estate property tax paid. Include only property tax on land which is reasonably necessary for the use of your dwelling as a home. Enter the amount of State of PA rebate received in 2013 on line 13a and that received from Bensalem Township on line 13b. Part C -- 2013 Household Income When completing lines 14 through 21, combine the total income received by you and your spouse as well as any other residents of your home during 2013. Note: This includes both taxable and non-taxable income and is NOT subject to the deductions on federal or state personal income tax forms. Income means all income from whatever sources including salaries, wages, bonuses, commissions, income from self-employment, alimony, support money, cash public assistance and relief, the gross amount of any pensions or annuities including railroad retirement benefits, all benefits under the Federal Social Security Act (except Medicare benefits), all income from state unemployment insurance and veterans disability payments, all interest received from federal, state, or local government, income from capital gains, rentals, worker s compensation insurance benefits and proceeds and gifts of cash or property if they exceed a total value of three hundred dollars ($300). Income shall not include surplus food or other non-cash relief supplies by a governmental agency. Review of tax return may be required. Line 14: Wages, salaries and other compensation: List the total amount received in 2013 by all residents of the household. Line 15: Social Security, SSI, and Railroad Retirement: List 50% of the total combined annual amount received by all residents of the household. Attach a statement of 2013 earnings from the Social Security Office. Line 16: Pensions and Annuities: The full amount of all types of pensions and annuities received in 2013 must be included. List the source of this income. Line 17: Interest and Dividends: Include interest and dividends credited or received during 2013 from any source, regardless of whether you actually received the cash. Be sure to include both taxable and non-taxable income. Line 18: Capital Gains: Include the entire amount of capital gains (Long Term and Short Term) realized during 2013. Capital losses may only be used to offset capital gains. Attach statement to verify amounts. Line 19: Cash Gifts, Life Insurance, and Death Benefits: Include cash gifts unless they do not total $300; life insurance and death benefits unless they are less than $5,000. Line 20: State and Local Grants/Rebates: Include rebates or grants of assistance received from state and local governments. This includes the rebate received from Bensalem Township. Line 21: Other Income: Report the total amount of all other types of income (including rental), received by all residents of the household during 2013 on line 21. Line 22: Total Household Income: Add lines 14 through 20 and enter the total at line 22.
SPECIFIC INSTRUCTIONS (Continued) Part D -- Tax Assistance Line 23: Enter total household income from line 22. Line 24: Enter total School Real Estate Tax paid from line 12. Line 25: Enter total amount of assistance from the table below: Household Income Maximum Assistance $ 0-4,999 $ 750 5,000-5,999 700 6,000-6,999 650 7,000-7,999 605 8,000-8,499 565 8,500-8,999 530 9,000-9,499 495 9,500-9,999 460 10,000-10,499 425 10,500-10,999 395 11,000-11,499 365 11,500-11,999 335 12,000-12,499 305 12,500-12,999 280 13,000-13,499 255 13,500-13,999 230 14,000-14,499 205 14,500-14,999 180 15,000-15,499 160 15,500-15,999 140 16,000-16,499 120 16,500-16,999 100
(Print in ink or type) BENSALEM TOWNSHIP SCHOOL DISTRICT BENSALEM, PA 19020-1898 PROPERTY TAX ASSISTANCE FORM Part A -- CLAIMANT'S IDENTIFICATION 1. Name 2. Address 3. Phone 4. Birth / / Date: Month Day Year Attach Proof of Age (If this is your first time applying) 5. Social Security No. 6. Spouse's First Name 7. Spouse's / / Birth Date: Month Day Year 8. Spouse's Social Security No. 9. Address Listed on Property Tax Bill 10. Owned Property / / Since Month Day Year 11. Is the Homestead Exclusion applied to the Tax bill of THIS property? Yes No Part C 2013 HOUSEHOLD INCOME 14. Wages, Salaries & Other Compensation $ 15. Social Security & Railroad Retirement Benefits** $ 16. Pensions, Annuities List Source: $ 17. Interest & Dividends $ 18. Capital Gains $ 19. Cash Gifts over $300, Life Insurance & Death Benefits over $5,000 $ 20. State and Local Rebates $ 21. Other Income $ 22. Total Household Income $ Attach Proof of Income for 2013 **Note 50% - See Line 15 instruction. PART B -- REAL ESTATE TAX PAID PART D -- TAX ASSISTANCE 12. Amount of 2013 School Real Estate Tax paid on property listed on line 10. Attach receipt of tax paid $ 13a. Amount of Commonwealth of PA rebate received in 2013. (Also include on Line 20) $ 13b. Amount of Bensalem Township Taxpayer Grants. (Also include on Line 20) 23. Total Household Income (Line 22) $ 24. Total School Real Estate Tax paid (line 12) $ 25. Amount of Assistance (see table on Instruction Sheet) $ $ (Assistance May Not exceed Net Tax Paid) Fraudulent claims will be disallowed in full and a 25% penalty will be imposed. Interest will also be charged on fraudulent claims. I declare that I prepared this return and that to the best of my knowledge and belief it is true, correct, and complete. I certify that the amount of refund requested from the School District and State Rebate Programs does not exceed the amount I actually paid in 2013 School District Real Estate Tax. Claimant's Signature Date Signature of Preparer Date (If other than claimant) - Phone No.
Office Use Only 1. Date Received: Age: Taxes Paid: Total Rebates from state or local government: 2. Verification Received for: Income: 3. Approved for: Amount: Assistance 4. Signed Date: /fjf