DR 0104PTC (11/21/22)
                                                          COLORADO DEPARTMENT OF REVENUE
                                                          Denver CO 80261-0005
*220104PT19999*                                           Page 1 of 2

                                                          (1063) 

         2022 Colorado Property Tax/Rent/Heat Rebate Application
         Mark here if this application is being filed to correct a previously filed 2022 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 2022, you must include a list of addresses at which you lived 
during 2022 and the dates you lived at each location.
Check the first box that applies to you or your spouse/partner. If none apply, do not fill out this form because you do not qualify for this rebate.

A        Age 65 or older on December 31, 2022.

B        A widow or widower at least 58 years of age on December 31, 2022.

C        Totally disabled for all of 2022 and received payment of full benefits from Social Security, SSI or the 
         Department of Human Services based solely on such disability.

D        Totally disabled for all of 2022 and received payment of full benefits from a bona fide 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).

                                                DR 0104PTC (11/21/22) 
                                                COLORADO DEPARTMENT OF REVENUE 
                                                Denver CO 80261-0005 
*220104PT29999*                                 Page 2 of 2
Name                                                                                     Account Number

List in the boxes below the TOTAL amount(s) received January through December 2022. 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 2022. If your 
    Medicare premiums were paid by Medicaid, enter 0.                                               1

2.  Social Security, SSI and/or A.N.D. benefits                                                     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 2021 property tax in 2022, enter amount here.                                        8                           00

9.  If you paid rent, enter the total for the year here.                                            9                            00

10. If you    10                                                                                                                 00                       paid heat or fuel expenses, enter the total for the year here.  
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 $153 if you are single, or $306 if you file jointly.
14. If you qualify, we will evaluate your eligibility for the Income Qualified Senior Housing Income Tax Credit. See Instructions

               Routing Number                                         Type:              Checking       Savings
Direct
               Account Number
Deposit

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