North Dakota Application For Senior Citizen Or Permanently And Totally Disabled Renter's Property Tax Refund

Application For Senior Citizen Or Permanently And Totally Disabled Renter's Property Tax Refund
Application For Senior Citizens or Permanently and Totally Disabled Renter's Property Tax Refund 2023
APPLICATION FOR SENIOR CITIZENS OR
PERMANENTLY AND TOTALLY DISABLED
RENTER'S PROPERTY TAX REFUND

2023

OFFICE OF STATE TAX COMMISSIONER
SFN 24777 (11-2023)

Applicant's Social Security Number

Name (If joint, use first name and initials of both)
Mailing Address (Did you live at this address for all 12 months?)

Yes

No

City, State, ZIP Code

Spouse's Social Security Number
Applicant's Date of Birth
Daytime Telephone Number

Physical Location of Property (Street Address, City, State, ZIP Code)
Landlord's Name

Telephone Number

Please make any necessary corrections on this form before submitting.

Must be postmarked by May 31, 2024
Office of State Tax Commissioner
600 E Boulevard Ave., Dept. 127
Bismarck, ND 58505-0599
Phone: 701-328-3127
Fax: 701-328-3048

Certification of Rent Paid in 2023
1. Amount of annual rent paid personally by applicant for 2023
2. Utilities or items included in rent (see instructions on back of application)
a. Heat (line 1 x .14)
b. Water and garbage (line 1 x .02)
c. Lights (line 1 x .06)
d. Furniture and appliances (see instructions on back)
e. Total (add lines a, b, c and d)
3. Net rent paid (subtract line 2e from line 1)
Total Income for Calendar Year 2023
4. Applicant's and spouse's income from Social Security benefits
(exclude Medicare)
5. Applicant's and spouse's income from salary and wages
6. Applicant's and spouse's income from interest
7. Applicant's and spouse's income from other sources (S.S.I.,
net rental income, net income from business, capital gains,
unemployment compensation, etc.)
8. Dependent's income from all sources
9. Total income from all sources (add lines 4, 5, 6, 7 and 8)
10. Deductible medical expenses (see instructions)
11. Total income less medical expenses (subtract line 10 from line 9)
If the amount on line 11 exceeds $70,000, you are not eligible for the credit.

Refund Computation

If you want the Office of State Tax Commissioner to compute your refund, do not complete this section

12. Enter 20% of net rent paid (line 3 x .20)
13. Enter 4% of total income less medical expenses (line 11 x .04)
14. Amount of renter's credit (subtract line 13 from line 12). If line 13 is
larger than line 12, you are not eligible for the credit
I declare under the penalties of N.D.C.C. § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental matter,
that this return, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true,
correct, and complete return.
Signature of Applicant

Date

Signature of Preparer if other than Applicant

Date

2023 Application For Senior Citizen Or Permanently And
Totally Disabled Renter's Property Tax Refund For The Year 2023
SFN 24777 (11-2023), Page 2

Application For Senior Citizen Or Permanently And
Totally Disabled Renter's Property Tax Refund For The Year 2023
Any person 65 years of age or older with an income of $70,000 or less per year from all sources, including the income
of any person dependent upon him or her, may qualify for a renter's property tax refund up to a maximum of $400
annually.
Any person, regardless of age, who is permanently and totally disabled, with an income of $70,000 or less per year,
may also qualify for a renter's refund. A physician's certificate or written determination of disability from the Social
Security Administration must accompany only the first application.

Instructions for Numbered Lines on Front of Application
Line 2: The cost of the utilities and items provided
by the landlord are estimated by mulitplying the
rent paid in Line 1 by the following percentages:
2a: 14% for heat
2b: 2% for water and garbage
2c: 6% for lights
2d: Furniture and appliances range from
approximately $15 per month for used items in an
efficiency apartment to $100 per month for new
items in a two bedroom apartment. Do not include
an entry for additional furniture and appliances if
only the stove and refrigerator are furnished.
2e: Total (add lines a, b, c, and d)
Lines 4-9: Income from all sources includes the
income of a husband and wife, if they are living
together, and any other person dependent upon
the applicant. This income from all sources
includes, but is not limited to, social security
benefits, pensions, salaries, dividends, interest,
net gains from the sale of property, net rental
income, net profit from any business, including
ranching and farming, and unemployment
compensation. Life insurance death proceeds,
Workers' Compensation, and Veterans' Disability
are not included as income.

Line 10: Deductible medical expenses include
unreimbursed payments for:
Total amount of health and hospital
insurance premiums (please exclude
Medicare):
Medicine and drugs (prescription
medications only)
Doctor and dentist
Hospital costs
Hearing aids, eyeglasses, dentures,
lift chair, etc.
Transportation costs for medical care
(miles x $0.65):

Confidentiality. Income and medical expenses contained in this application are confidential. However,
they may be disclosed to the board of county commissioners and county auditor, as needed, to carry out
their official duties.
PRIVACY ACT NOTIFICATION
In compliance with the Privacy Act of 1974, disclosure of a social security number on this form is required under N.D.C.C.
§§ 57-01-15 and 57-02-08.1, and will be used for tax reporting, identification, and administration of North Dakota tax
laws. Disclosure is mandatory. Failure to provide the social security number may delay or prevent the processing of this
form.