Circuit Breaker Application

2021 TAX RELIEF ONLINE APPLICATION

APPLICATION FOR CIRCUIT BREAKER TAX RELIEF

Please fill out the following form.

(Step 1 / 5)

First Name

Last Name

Mailing Address

City

State

Zip Code

Phone Number

Year of Birth

Social Security #

If your home is a mobile home, check this box.

Serial Number

Can't find or don't have your account Number? To locate your Account Number you will need to call 801-851-8295 , or 801-851-8255 and we will help you retreive that number.

Can't find or don't have your Serial Number? To locate your Serial Number on your most recent Valuation or Tax Notice CLICK HERE

Check this box if someone other than the applicant is preparing and/or signing the form.

Name of Person Preparing This Form

Full Address

Telephone Number

(Step 2 / 5)

AFFIDAVIT

I/We hereby certify the following (mark all that apply):

I am a United States Citizen (required for all applications filed after June 30, 2009).

I am a qualified alien as defined in 8 U.S.C., Sec. 1641 and lawfully present in the United States.

My Alien Registration Number is:

My I-94 Number is:

MUST APPLY IN PERSON

I am a homeowner aged 66 years or older or will be by December 31, 2021.

I am a surviving spouse (widow/widower). New applicants must provide a copy of spouse's death certificate.

(Step 3 / 5)

LIST YOURSELF AND ALL PERSONS LIVING IN THE HOME AS OF JANUARY 1, 2021

A household is an association of all people living in the same dwelling, sharing furnishings, facilities, accommodations and expenses. Household income is income received by all members of the household (i.e., all residents of the home) as of January 1, 2021, not just the applicant.

List the Name(s), and Relationship(s) of ALL persons living in the residence:

Name

Age

Relationship

(Step 4 / 5)

PLEASE ANSWER EVERY QUESTION.

(Yes or No)

Yes No	Did you own and occupy the residence on January 1, 2021 and can claim it as your primary residence?
Yes No	Did anyone claim you as a dependent on their 2020 Federal tax return?
Yes No	Did anyone receive a tax credit because of you on their 2020 Federal tax return?
Yes No	Have you filed for tax relief in any other county in Utah or in any other State?
Yes No	Will you be a resident of the State of Utah for all of 2021?

(Step 5 / 5)

INCOME QUESTIONAIRE (Gross Income Limit is $34,167)

PLEASE ANSWER EVERY QUESTION. ALL DOCUMENTS ARE REQUIRED IF APPLICABLE

Yes No	Did you file a 2020 tax return with the IRS? If yes, please attatch a copy of your completed tax return, both personal and business, including all schedules and attachments.
Yes No	Did you receive Social Security Benefits in 2020? If yes, please attach your 2020 year-end benefits statement (Form 1099 SSA). If you do not have it, please get a copy of this statement from the local Social Security Administration Office.
Yes No	Did you receive Veterans Disability benefits in 2020? If yes, please attach verification from Veterans Administration.
Yes No	Did you receive retirement benefits from one of more sources in 2020? If yes, please attatch 2020 year-end statements or Form 1099 showing payout or withdrawal amounts from pensions, 401(k), 457, IRA accounts, annuities, life insurance or trust income.
Yes No	Did you receive dividends and other interest income in 2020? If yes, please attach any 1099 forms sent to you that show the total amounts received.
Yes No	Did you rent out a portion of your home in 2020? If yes, what is the percent of your home that is rented? %. In the event that part of the residence is rented, evidence that a bona fide rental relationship exists is required. Otherwise the tenant(s) will be considered household members for income purposes. Evidence will be either: Rental agreement and rent receipts, or An affidavit signed by the claimant and renter(s).
Yes No	Did you use a portion of your home in 2020 for a home based business? If yes, what is the percent of your home used for business? %. If yes, please attatch proof of your income from the business.
Yes No	Did you receive any other income in 2020, that is not listed above? (Wages, salary, alimony, child support, welfare, lottery, gambling income, inheritance, sale of property, or workers compensation, etc.) If yes, please include any W-2's, 1099's, or other documents that show the total income received.
Yes No	Did any of your household receive income in 2020? Any adult member who cannot provide documentation must admit an IRS Wage and Income transcript and/or Social Security earnings history. If any household member has zero income, they will be required to provide an IRS Wage and Income Transcript to show no income has been reported for them.
Yes No	Is the property in a trust? If yes, has the trust changed in the past year?