APPLICATION SAN FRANCISCO WORKING FAMILIES CREDIT OPENING A BANK ACCOUNT PAYS! Get more from the City when you use direct deposit! 1 st Time Applicants Only. Working Families Credit City & County of San Francisco Complete and return this form or take it to your tax preparer when you file your taxes. To download more applications, visit: www.workingfamiliescredit.org TAX YEAR 2011 Due April 17, 2012 PACKET INCLUDES: Program Information & Locations Application/4506T-EZ Form
Form 4506T-EZ (Rev. January 2011) Short Form Request for Individual Tax Return Transcript OMB No. 1545-2154 Department of the Treasury Request may not be processed if the form is incomplete or illegible. Internal Revenue Service Tip. Use Form 4506T-EZ to order a 1040 series tax return transcript free of charge, or you can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on Order a Transcript or call 1-800-908-9946. 1a Name shown on tax return. If a joint return, enter the name shown first. 1b First social security number or individual taxpayer identification number on tax return 2a If a joint return, enter spouse s name shown on tax return. 2b Second social security number or individual taxpayer identification number if joint tax return 3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (See instructions) 4 Previous address shown on the last return filed if different from line 3 (See instructions) 5 If the transcript is to be mailed to a third party (such as a mortgage company), enter the third party s name, address, and telephone number. The IRS has no control over what the third party does with the tax information. Third party name Telephone number City & County of San Francisco - HSA, Working Families Credit Program 415-557-6284 Address (including apt., room, or suite no.), city, state, and ZIP code P.O. Box 7988, San Francisco, CA 94120 6 Year(s) requested. Enter the year(s) of the return transcript you are requesting (for example, 2008 ). Most requests will be processed within 10 business days. 2011 xxxx xxxx xxxx Caution. If the transcript is being mailed to a third party, ensure that you have filled in line 6 before signing. Sign and date the form once you have filled in line 6. Completing these steps helps to protect your privacy. Note. If the IRS is unable to locate a return that matches the taxpayer identity information provided above, or if IRS records indicate that the return has not been filed, the IRS may notify you or the third party that it was unable to locate a return, or that a return was not filed, whichever is applicable. Signature of taxpayer(s). I declare that I am the taxpayer whose name is shown on either line 1a or 2a. If the request applies to a joint return, either husband or wife must sign. Note. For transcripts being sent to a third party, this form must be received within 120 days of signature date. Telephone number of taxpayer on line 1a or 2a Sign Here Signature (see instructions) Date Spouse s signature For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 54185S Form 4506T-EZ (Rev. 01-2011) Date 1
City and County of San Francisco APPLICATION FOR SAN FRANCISCO WORKING FAMILIES CREDIT This application must be submitted or postmarked by April 17, 2012 to be considered. AM I ELIGIBLE? *FINAL ELIGIBILITY WILL BE DETERMINED BY THE CITY AND COUNTY OF SAN FRANCISCO. Complete this checklist to determine your eligibility for the credit. 1. I have NEVER received the San Francisco Working Families Credit before. True False 2. (If married), my spouse has NEVER received the credit either. True False 3. I am claiming the federal Earned Income Tax Credit. 4. I claimed at least one qualifying dependent child on my federal tax filing who is either: A) under age 19; B) under age 24 and a full-time student; or C) permanently and totally disabled. 5. I am a current San Francisco resident and I was a San Francisco resident at the time of my federal tax filing. True True True False False False If you answered TRUE to all statements, complete this form and form 4506T-EZ. If you answered FALSE to any statement, STOP. You cannot apply for the credit. LAST NAME: (PLEASE print in CAPITAL letters) FIRST NAME: (PLEASE print in CAPITAL letters) MI SOCIAL SECURITY NUMBER: SPOUSE S LAST NAME: (If filing taxes jointly) SPOUSE S FIRST NAME: SPOUSE S SOCIAL SECURITY NUMBER: ADDRESS: PHONE NUMBER: ( ) CITY: STATE: ZIP: DATE OF BIRTH ( MM / DD / YYYY ): / / Stay connected to the WFC Program year-round! E-MAIL ADDRESS: You may receive your credit in the form of a check or by direct deposit. We encourage you to use direct deposit. To receive the maximum credit amount of $125 you must use direct deposit. If you ask for a paper check, you will only receive $50. I would like to receive a I would like to receive $125 direct deposited to my bank account.* $50 check. You must mark the type of account being used: Checking account (YOU MUST ATTACH A VOIDED CHECK FROM THE ACCOUNT LISTED BELOW.) Savings account Bank Routing Number: Account Number: *If there Is a change to your bank account InformatIon, you must contact the Wfc Program to ensure you receive the full credit. Check here if you do not wish to receive information about other programs that help working families (e.g. Medi-Cal, Healthy Families, Food Stamps) Check here if you do not wish to be contacted to help evaluate the success of this program. Certification To the best of my knowledge the information provided on this application is true and correct. I understand that the City and County of San Francisco may verify the information using my tax transcript from the Internal Revenue Service. I know that Working Families Credit benefits may be denied if any information on this application is found to be untrue or is left off the application. I understand that receipt of the credit is subject to availability of funds. Applicant s Signature Date / / Please complete the 4506t-eZ form on Page 1. 4 1 Do not attach any original tax documents or copies 2011 2
City and County of San Francisco APPLICATION FOR SAN FRANCISCO WORKING FAMILIES CREDIT WHAT IS THE WORKING FAMILIES CREDIT? The Working Families Credit is a commitment by the City of San Francisco to help low-income families keep more of what they earn. Eligible families that use direct deposit can receive a Credit up to $125 from the City in addition to their federal Earned Income Tax Credit (EitC) payment, subject to available funds. Eligible families that ask for a paper check will only receive a Credit for $50 in addition to their federal EitC payment. This credit will not count as income for determining eligibility for most public benefit programs. Please note: The Credit is only available to eligible applicants who have NEVER received the credit before. Step 1: Check if you are eligible INSTRUCTIONS You are eligible if you meet all six of the criteria below: 1. You (and your spouse, if married) have NEVER received the San Francisco Working Families Credit before. 2. You earned less than $49,100 in 2011. 3. You claim and qualify for the federal Earned Income Tax Credit. 4. You are claiming at least one qualifying dependent child on your federal tax filing who is either: A) under age 19; B) under age 24 and a full-time student; or C) permanently and totally disabled. 5. You live in San Francisco. 6. You have filed taxes by the April 17 th deadline. Step 2: Complete the application Complete the application forms on page 1 and 2. You must complete and sign both pages. You can complete the application yourself or have a tax preparer complete it for you. For help completing the application call 1-800-358-8832 or 2-1-1, or see the list of tax preparation sites on page 5. Step 3: For direct deposit to a checking or savings account, you must mark the correct boxes on page 2 and provide the complete routing number and account number in the spaces provided. For direct deposit to a checking account, you must attach a voided check to your application. Contact your bank or credit union for the routing number for receiving an electronic deposit from a 3rd party. Step 4: Submit by April 17 th, 2012 Send your completed application to: City and County of San Francisco - HSA WFC Program PO Box 7988 San Francisco, CA 94120 or deliver to hsa, 170 Otis Street, reception desk (first floor), or any free tax preparation site in San Francisco. Applications must be postmarked or delivered by April 17 th, 2012. Do not attach your tax documents to the application. Step 5: Receive your Working Families Credit in October If your application is successful, you will receive your Working Families Credit in October 2012, subject to availability of funds. 3
Working Families Credit City & County of San Francisco Stay Connected to the Working Families Credit Program All Year! Save Hundreds of Dollars on Utility Bills, Auto Insurance, Health Care Costs, and More! For More Information about Ways to Save Money on Your Everyday Expenses, visit us online: www.workingfamiliescredit.org For more information about the WFC Program, call 415-557-6284 or send an email to wfc@sfgov.org 4
City and County of San Francisco APPLICATION FOR SAN FRANCISCO WORKING FAMILIES CREDIT You can complete this application yourself or with the help of your tax preparer. Completed applications may be mailed per the instructions or dropped off at: San Francisco Human Services Agency, 170 Otis Street, reception desk (first floor) Free Tax Preparation Sites in San Francisco FREE * TAX PREPARATION SITES IN SAN FRANCISCO FOR HOURS OF OPERATION, CALL: 1-800-358-8832 OR 2-1-1 *For families with income of less than $50,000 BAYVIEW HUNTERS POINT City College of San Francisco-Southeast 1800 Oakdale Ave., Room 203, (415) 391-7427 Bayview Hunters Point, Wells Fargo (Tax-Aid) 3801 3rd St. Ste 116, (415) 963-8633 Southeast Community Facility (Tax-Aid) 1800 Oakdale Ave., (415) 963-8633 True Hope Church 950 Gilman Ave. Ste C, (415) 410-4016 YMCA Bayview Hunters Point 1601 Lane St., (415) 822-7728 CASTRO/UPPER MARKET SF LGBT Center 1800 Market St., (415) 865-5658 CHINATOWN Chinese American Citizens Alliance (AARP) 1044 Stockton St. Chinese Newcomers Service Center 777 Stockton St. #104, (415) 421-2111 x 699 NECFCU - Chinatown 17 Walter U. Lum Place, (415) 434-0738 Salvation Army Chinatown (Tax-Aid) 1450 Powell St, (415) 963-8633 CNSC - Wu Yee Children s Services 888 Clay St., Lower Level, (415) 421-2111 x 699 DIAMOND HEIGHTS Vista Del Monte Apartments 49 Gold Mine Dr., (415) 695-0449 EXCELSIOR City College of San Francisco - Ocean 50 Phelan Ave. Multi-Use Bldg. Room 298 (415) 391-7427 CCSF - ABG Business Honors Club 50 Phelan Ave., ccsfvita@gmail.com OMI Neighborhood Beacon Center (Tax-Aid) 241 Oneida Ave., (415) 963-8633 FISHERMAN S WHARF Aquatic Park Senior Center (AARP) 890 Beach St., (415) 775-1866 MISSION Arriba Juntos 1850 Mission St., (415) 487-7834 Bayanihan Community Center (Tax-Aid) 1010 Mission St., Ste B, (415) 963-8633 Career Link -One Stop Center/MEDA 3120 Mission St., (415) 557-5510 City College of San Francisco -Mission 1125 Valencia St., (415) 391-7427 Employment Information Center (EIC)/MEDA 170 Otis St., (415) 557-5510 Annunciation Cathedral (Tax-Aid) 245 Valencia St., (415) 963-8633 MEDA-Plaza Adelante 2301 Mission St. Ste 301 (415) 282-3334 x 117 or x 125 St. Peter s Parish School (Tax-Aid) 1249 Alabama St., (415) 963-8633 The Women s Building 3543 18th St., (415) 431-1180 x 16 POTRERO Homeless Prenatal Program 2500 18th St., (415) 546-6756 RICHMOND NECFCU - Agape Community Center 378 18th Ave., (415) 434-0738 George Washington High School (Tax-Aid) 600 32nd Ave., Bldg. T-1, (415) 963-8633 SOMA CalFresh & CAAP Office/MEDA 1235 Mission St., (415) 557-5510 NECFCU - SOMA 992 Howard St., (415) 434-0738 San Francisco Aids Foundation (Tax-Aid) One Sixth St., (415) 487-8000 SUNSET San Francisco State University 1600 Holloway Ave.,Science Bldg, Room 205 (415) 338-1079 Stonestown YMCA (AARP) 3150 20th Ave., (415) 242-7135 Sunset Neighborhood Beacon Center (Tax-Aid) 3925 Noriega St. (415) 963-8633 TENDERLOIN Federal Building (AARP) 450 Golden Gate Ave. Floor 1 (415) 522-4307 Glide Memorial Church (Tax-Aid) 330 Ellis St., Freedom Hall (415) 963-8633 Goodwill (Tax-Aid) 1500 Mission St. (415) 963-8633 NECFCU - Tenderloin 288 Jones St., (415) 434-0738 St. Mary s Senior Services (AARP) 450 Stanyan St. (415) 750-5800 Tenderloin Community School (Tax-Aid) 627 Turk St. (415) 963-8633 The Vietnamese Community Center of SF 766 Geary St. (415) 351-1038 UC Hastings College of the Law 200 McAllister St. (415) 565-4600 TREASURE ISLAND TIHDI 850 Ave. I, (415) 274-0311 VISITACION VALLEY Asian Pacific American Community Center 2442 Bayshore Blvd. (415) 587-2689 5