KITSAP COUNTY ASSESSOR Phil Cook

KITSAP COUNTY ASSESSOR Phil Cook Michael Eastman 614 Division Street MS-22 Phone: (360) 337-7160 Chief Deputy Port Orchard WA 98366 Fax: (360) 337-4874 PROPERTY TAX EXEMPTION PROGRAM Enclosed is a 2015 property tax exemption application packet. Eligibility is based on your 2014 income, and age or disability, and ownership/residency information. Complete and return the following: 1. Application (4 pages); and 2. All other forms that may pertain to you; and 3. Copies of all income documentation (See instructions); and 4. A copy of your valid driver s license or State issued photo identification. Instructions are attached to help complete the application and the income section. INCOMPLETE APPLICATIONS WILL BE RETURNED. DOCUMENTATION REQUIRED You must provide documentation for all income sources, or this application will be returned to you. If you file a tax return, this documentation must include a complete copy of your IRS tax return, year-end Social Security statement, retirement or pension statement(s), W-2 form and form 1099 s. If you do not file a tax return, this documentation must include copies of all year-end income documents such as: Social Security 1099-SSA, retirement/pension/annuity 1099-R statement(s), W- 2 form and all other form 1099 s. You must include documentation for any non-taxable income such as supplemental security income(ssi), State cash and food assistance, military benefits (CRSC, CRDP, SBP Costs), veterans benefits, and disability benefits State L & I and U.S. Labor Workman s Compensation (OWCP). You must also include documentation for any allowable out-of-pocket expenses you are deducting from your income. You must include a copy of your valid driver s license or State issued photo identification. To protect your privacy, please do not send us original documents, as they will be destroyed. The application and all supporting documents can be submitted at any time during the year. All applications are processed in the order received in the office, and you will be notified by mail once the process is completed. You can choose to return the completed Application Packet by mail, fax, or you can bring it to our office in person. No appointment is necessary. The mailing address is: KITSAP COUNTY ASSESSOR 614 DIVISION ST MS-22 PORT ORCHARD WA 98366 Fax: 360-337-4874 If you have any questions, or need assistance, please contact our office at 360-337-7160 or you may send an email to Lmcphee@co.kitsap.wa.us. Office hours: Monday Thursday 8:00 4:30, Fridays 9:00 1:00, & Closed Holidays

Exemption Program Eligibility and Relief Eligibility Requirements To be eligible for this program, the claimant must meet the age or disability, and ownership, and residency, and income requirements during the assessment year the year before the property tax is due (tax year). Age and Disability You must be at least 61 years old on or before December 31 of the assessment year or unable to work because of a disability, or a veteran entitled to and receiving compensation from the Department of Veterans Affairs at a 100% disability rating for a service-connected disability. Your application must include proof of your age or disability. Ownership and Residency You must own and occupy the qualifying primary residence during the assessment year. You must physically occupy the home for more than 6 months a year to continue eligibility status. However, if you are confined to a hospital, nursing home, assisted living or adult care facility, your home may still be considered your primary residence. If you transferred your home under a revocable trust, you must retain full use of the property and be able to revoke the trust and take ownership at any time. A Declaration of Trust and a copy of your Trust Agreement are required to be filed with your application. If you are living in your home under the terms of an irrevocable trust or life estate, you may still qualify for the exemption. A recorded document outlining terms of the agreement is required. Income You must have an annual gross income of $35,000 or less to qualify. This includes the combined disposable income of the claimant, spouse/domestic partner and any co-tenants. A co-tenant is a person who has ownership interest and resides in the primary residence. Partial exemption may be granted on your percent ownership interest if the co-tenants do not occupy the residence. Disposable income means all gross taxable and non-taxable income, including (but not limited to) Social Security, retirement, disability pension, veterans/military benefits (except service-connected disability), interest, dividends, wages, capital gains, rental income, State cash and food assistance, etc. You cannot deduct depreciation or losses. Non-reimbursed costs for prescription drugs, Medicare premiums (other health insurance, Medicare supplemental, or medigap are not eligible), in-home care, or nursing home expenses for the claimant or spouse/domestic partner can be deducted from income. The exemption is available for your primary residence and up to five acres* of land. A mobile home may qualify, even if the land where the mobile home is located is leased or rented. * The exemption is available for a primary residence and one acre of land. If zoning and land use regulations require more than one acre of land per residence in the area where you live, you may be eligible for a property tax exemption on up to five acres of land. Application Procedure 1. Obtain an application packet from the Assessor's Office any time during the tax year. 2. Complete the application and any other necessary forms. Copies of income documents and proof of age or disability and residency are required with your application. 3. Submit your application in person, by mail, email or fax. 4. We will process the application and notify you by letter of your qualification status.

Tax Relief Qualifying information for age or disability and income and ownership and residency is based on the assessment year the year before the property tax is due (tax year). There are three levels of tax reduction, based on income: Income up to $25,000 Income of $25,001 $30,000 Income of $30,001 - $35,000 Exempt from voted levies and a $60,000 or 60% reduction in assessed value, whichever is greater. This means that if your property were valued at $90,000, the value upon which your taxes are based would be $30,000. Exempt from voted levies and a $50,000 or 35% reduction in assessed value (not to exceed $70,000), whichever is greater. This means that if your property were valued at $90,000, your taxes would be based on a value of $40,000. Exempt from voted levies only, such as local school maintenance and operation levies. Additionally, the value of your residence is frozen as of January 1, 1995, or January 1 of the initial application year, whichever is later. Refunds If you have paid prior years taxes because of a mistake, oversight, or a lack of knowledge, you may apply for a refund by filing an application for refund with the county assessor. You must file the application within three years of the date the taxes were owed. Refunds will not be made beyond the three-year period but could establish your frozen value base and reduce delinquent taxes. Tax Deferral Program This deferral program postpones payment of your property taxes and any special assessments. On your behalf, the Department of Revenue pays the deferred amount to the county where you live. The amount of the postponed tax and/or special assessment, plus five-percent interest, becomes a lien in favor of the state until the total amount is repaid. To qualify, you must be at least 60 years of age, or disabled from employment, or a veteran with 100% service connected disability and have an annual income of $40,000 or less. Limited Income Deferral Program Under this deferral program, you can postpone payment of taxes having the Dept. of Revenue pays your second half taxes and/or special assessments (due October 31) on your behalf. To qualify, you must meet the ownership (more than 5 years), residency (occupying the home January 1 of application year), income (less than $57,000), and equity requirements. In addition, your first half tax payment (due April 30) must already be paid. Applications are due by September 1. Questions or Application Requests Please feel free to call us at 360-337-7160 if you have further questions or would like an application. The local lines are: Olalla 851-4147, or Bainbridge Island 842-2061. Department of Revenue informational brochures are available from the Assessor s Office for all programs. Office hours: Monday-Thursday 8:00-4:30 & Fridays 9:00-1:00 Closed on holidays. Kitsap County Assessor's Office 614 Division Street MS 22 Port Orchard, WA 98366 E-Mail: assessor@co.kitsap.wa.us Web-site: www.kitsapgov.com/assr Laws and Rules: Exemptions RCW 84.36.379-389 and WAC 458-16A 100-150 Deferrals - RCW 84.38 and WAC 458-18 Limited Income Deferrals RCW 84.37 & WAC 458-18A

Instructions for Completing the Application Page 1 - Parts 1 through 5 Provide the information requested in Parts 1 through 4. Leave the County Use Only areas blank. In Part 1, a cotenant is someone who lives with you and has an ownership interest in your home. Your signature in Part 5 must have two witnesses. If you do not have anyone available to witness your signature, take your completed application to the Assessor s Office and someone there will witness your signature. To avoid delays in processing your application, remember to answer all questions and include all of the required documentation. If you have questions about what to include, contact your County Assessor s Office. Page 2 - How is disposable income calculated? The Legislature gave disposable income a specific definition. According to RCW 84.36.383(5), disposable income is adjusted gross income, as defined in the federal internal revenue code, plus all of the following that were not included in, or were deducted from, adjusted gross income: Capital gains, other than a gain on the sale of a principal residence that is reinvested in a new principal residence; Amounts deducted for losses or depreciation; Pensions and annuities (annuities also include income from unemployment, disability, and welfare); Social Security Act and railroad retirement benefits; Military pay and benefits other than attendant-care and medical-aid payments; Veterans pay and benefits other than attendant-care, medical-aid payments, veterans disability benefits, and dependency and indemnity compensation; and Dividend receipts and interest received on state and municipal bonds. This income is included in disposable income even when it is not taxable for IRS purposes. Line A: Enter your (AGI) adjusted gross income from your IRS tax return. Lines B-J: If you filed a tax return, enter all amounts that were excluded or deducted from the AGI see each line item. If you do not file an IRS tax return, you must still report all gross income sources on lines B J. Include all income sources and amounts received by you, your spouse/domestic partner, and any co-tenants during the application/assessment year (the year before the tax is due). If you report income that is very low or zero, attach documentation including 12 months bank statements showing how you meet your daily living expenses. Use Line K to report any income not reported on your tax return and not listed on Lines A through J. Line K Report all household income not already included or discussed on Lines A through J. Include foreign income not reported on your federal tax return and income contributed by other household members not shown in Part 1. Provide the source and amount of the income. What if my income changed in mid-year? If your income was substantially reduced (or increased) for at least two months before the end of the year and you expect that change in income to continue indefinitely, you can use your new average monthly income to estimate your annual income. Calculate your income by multiplying your new average monthly income (during the months after the change occurred) by twelve. Example: You retired in September and your monthly income was reduced from $3,500 to $1,000 beginning in October. Multiply $1,000 x 12 to estimate your new annual income. Lines L - O - What is combined disposable income? RCW 84.36.383(4) defines combined disposable income as your disposable income plus the disposable income of your spouse or domestic partner and any co-tenants, minus amounts paid by you or your spouse or domestic partner for: Prescription drugs; Treatment or care of either person in the home or in a nursing home, boarding home, or adult family home; and Health care insurance premiums for Medicare. (At this time, other types of insurance premiums are not an allowable deduction.) Care or treatment in your home means medical treatment or care received in the home, including physical therapy. You can also deduct costs for necessities such as oxygen, special needs furniture, attendant-care, light housekeeping tasks, meals-on-wheels, life alert, and other services that are part of a necessary or appropriate inhome service. Special instructions for Line P No IRS tax return. If you had adjustments to your income for any of the following and you did not file an IRS return, report these amounts on Line P and include the IRS form or worksheet you used to calculate the amount of the adjustment. Certain business expenses for teachers, reservists, performing artists, and fee-basis government officials Self-employed health insurance or contributions to pension, profit-sharing, or annuity plans Health savings account deductions Moving expenses IRA deduction Alimony paid Student loan interest, tuition, and fees deduction Domestic products activities deduction Page 3 Other information & income sources Answer all Yes/No questions pertaining to the specific assessment year providing documentation when required. What are the program benefits? The taxable value of your home will be frozen as of January 1 in the year you first qualify for this program. Even though your assessed value may change, your taxable value will not increase above your frozen value. In addition, your combined disposable income determines the level of reduction (exemption) in your annual property taxes. Income Level of Reduction 0 - $25,000 Exempt from regular property taxes on $60,000 or 60% of the valuation, whichever is greater, plus exemption from 100% of excess levies. $25,001 - $30,000 Exempt from regular property taxes on $50,000 or 35% of the valuation, whichever is greater, not to exceed $70,000, plus exemption from 100% of excess levies. $30,001 - $35,000 Exempt from 100% of excess levies.

Documentation to Include You must provide copies of documentation to the Assessor for all income received by you, your spouse/domestic partner, and any co-tenants. A. Federal Tax Forms If you file a federal tax return, provide a complete copy including, but not limited to, all of the following forms or schedules that are part of your federal return. IRS Form 1040, 1040A, or 1040EZ Schedule B - Interest & Ordinary Dividends Schedule C - Profit & Loss from Business Schedule D - Capital Gains & Losses Schedule E - Supplemental Income & Loss Schedule F - Profit & Loss from Farming Form 1116 Foreign Tax Credit Form 4797 - Sales of Business Property Form 6252 - Installment Sale Income Form 8829 - Expenses for Business Use of your Home Social Security Statement (Generally, SSA 1099) K-1 s Non-IRS Filers: If you do not file an IRS return, you must provide documentation of all income received by you, your spouse/domestic partner, and any co-tenants. B. Other Documents (Filers and Non-Filers): Include copies of standard federal forms and documents used by others to report income they paid out including, but not limited to, the following: 1. W-2 s - Wage & Tax Statement W-2-G - Certain Gambling Winnings 2. 1099 s: 1099-B - Proceeds from Broker & Barter Exchange 1099-Div - Dividends & Distributions 1099-G Unemployment Compensation, State & Local Income Tax Refunds, Agricultural Payments 1099-Int - Interest Income 1099-Misc - Contract Income, Rent & Royalty Payments, Prizes 1099-R - Distributions from Pensions, Annuities, IRA s, Insurance Contracts, Profit Sharing Plans 1099-S - Proceeds from Real Estate Transactions RRB-1099 - Railroad Retirement Benefits SSA-1099 - Social Security Benefits C. Other Income Sources If you have income from other sources and you did not receive a W2 or 1099 for the income you received, provide the following: copies of your monthly bank statements with a statement describing the type of income received (e.g. workers compensation, state cash and food assistance, tips, cash earned from yard sales or odd jobs, rental income, groceries purchased for you in return for a room in your house, etc.). a statement from the organization that issued the payments (DSHS, WA Labor & Industries, U.S. Dept. of Labor (OWCP), etc.); DFAS CRSC, CRDP, SBP Costs. Provide Retiree/Annuitant Account Statement or bank statements. PROOF OF EXPENSES Provide documentation for the allowable out-ofpocket expenses that were not reimbursed by insurance or a government program Only for the following items: Care in a nursing home, assisted living, or licensed adult family/boarding home In-home care Prescription drugs (Most pharmacies will provide a print-out for the year if you ask for one.) Medicare premiums only (Part B; Part C - Medicare Advantage; Part D Prescription Drug insurance plans. Not medigap or other supplemental insurance). PROOF OF AGE OR DISABILITY AND PROOF OF OWNERSHIP AND RESIDENCY You must provide documentation to the Assessor demonstrating you meet the age or disability, ownership, and residency requirements. A copy of your driver s license or State issued photo identification to verify date of birth and residency. If your eligibility is based on a disability, a copy of your disability award letter from SSA or VA, or a Proof of Disability statement completed and submitted by your physician. A complete copy of your trust documents, if applicable.

TY2015 Senior Citizen and Disabled Persons Exemption from Real Property Taxes Chapter 84.36 RCW 1. Applicant Name County Use Only 2014 Assessment for 2015 Taxes Spouse/Domestic Partner or Co-tenant Name Year ZONING: Year Mailing Address City, State, Zip Home Phone Email Address Cell Phone Approved for Exemption on: 60% of value but not less than $60,000 35% of value but not less than $50,000 or more than $70,000 Excess levies only Denied (reason): Processed by: Date: 2. Please check the appropriate box. Proof of age or disability is required. I am or will be 61 years of age or older by December 31 of the assessment year on which this exemption is based. (The assessment year is the same as the income year used to qualify and is the year before the property tax is due.) I am under 61 years of age and I am retired from regular gainful employment due to a disability as of December 31 of the assessment year. Disability Determination Date: I am a veteran with a 100% service connected disability as of December 31 of the assessment year. I am the surviving spouse/domestic partner of a person who was previously receiving this exemption and I was at least 57 years of age in the year my spouse/domestic partner passed away. Current Marital Status: Single Married Divorced Legal Separation Widowed Date of death: Registered Domestic Partnership Terminated a Registered Domestic Partnership Applicant Birth date: Spouse/Domestic Partner Birth date: Co-Tenant Birth Date: 3. Ownership and Residency: Date Property Purchased/Acquired: Ownership Type: Owner/Occupant Life Estate/Lease for Life Revocable Trust Irrevocable Trust Yes No Have you received an exemption before now? If Yes: When: Where: Yes No Did you sell your former residence? If Yes: When: Where: 4. Property Description: Parcel or Account Number: Physical Address: Address My residence is a Single family home One unit of a multi-unit dwelling (duplex/condominium) Housing Co-op Mobile Home: Year: Make: Model: Do you own the land where the mobile home is located? Yes No This property includes (check all that apply): My principal residence and up to 1 acre of land. My principal residence and more than 1 acre* of land - the total parcel or lot size is: Acre(s) More than one dwelling or improvement (i.e. 2 nd residence, mobile home, detached garages, pole buildings, workshop, commercial buildings or other improvements not typically part of a residential parcel) *If your parcel is larger than one (1) acre and your local zoning/land use regulations require more than one (1) acre per residence in the area where you live, you may be eligible for an exemption for your entire parcel, up to five (5) acres. 5. By signing this form I confirm that I: Have completed the application to the best of my ability and the required documentation is included. Understand it is my responsibility to notify you if I have a change in income or circumstances and that any exemption granted through erroneous information is subject to the correct tax being assessed for the last five years, plus a 100 percent penalty. Declare under penalty of perjury that the information in this application packet is true and complete. Request a refund under the provisions of RCW 84.69.020 for taxes paid or overpaid as a result of mistake, inadvertence, or lack of knowledge regarding exemption from paying real property taxes pursuant to RCW 84.36.381 through 389. You must have two people witness your signature. Otherwise, you must present your application in person and an employee of the Kitsap County Assessor s Office will witness your signature. Signature of Applicant Date 1 st Witness Signature (If not signed at Assessor s Office) Date By: Guardian or POA for Applicant, If Applicable Date 2 nd Witness Signature (If not signed at Assessor s Office) Date (MUST provide copy of Power of Attorney) Signature of Assessor or Deputy Date New Application (12/1/14) PAGE 1 City

Combined Disposable Income Worksheet 2014 County Use As defined in RCW 84.36.383 (4) and (5) and WAC 458-16A-100 (6) and (12) Income Year Worksheet NOTE: If worksheet is not completed by applicant, the Assessor s Office shall calculate the disposable income and provide a copy with the approval/denial letter. Income: A. Yes No Do you file a federal tax return? If yes, enter your (AGI) Adjusted Gross Income from your federal tax return. Attach a complete copy of your return. If yes, enter income amounts on lines B K that were excluded or deducted from your AGI. If no, enter ALL gross income sources on lines B K below. B. Yes No Do you have capital gains that were not reported in your AGI? Do not add the gain from the sale of a primary residence if you used the entire gain to purchase a replacement residence in the same year. Do not use losses to offset gains. C. Yes No Do you have deductions for losses included in your AGI? If yes, the losses must be added back to the extent they were used to offset/reduce income. (Ex: On Schedule D, you reported a ($10,000) loss but the loss was limited to ($3,000), shown on Line 13 of your 1040. Add the ($3,000) loss used to offset/reduce your income.) (Ex: You filed two Sch C s one with a ($10,000) loss and one with a $5,000 net income. A net loss of ($5,000) was reported on your 1040, Line 12. Add back the ($10,000) loss.) D. Yes No Did you deduct depreciation expense in your tax return? If yes, that expense must be added back to the extent the expense was used to reduce your income. (Ex: Net loss reported: If you deducted depreciation as a business and/or rental expense that resulted in a loss, recalculate the net income/loss without the depreciation expense. If there is still a net loss enter -0- here, if there is net income enter the net income here.) E. Yes No Do you have nontaxable dividend or interest income, or, income from these sources that was not included in your AGI? If yes, add that income here. Include non-taxable interest on state and municipal bonds. F. Yes No Do you have pension, annuity or IRA income, or, income from these sources that was not included in your AGI? If yes, report the amounts here. (Ex: You received $10,000 in distributions. The taxable amount was $6,000. Report the nontaxable $4,000 here.) Do not include non-taxable IRA distributions. G. Yes No Do you receive military pay and benefits that is nontaxable, or, income from these sources that was not included in your AGI? If yes, report that income here, (CRSC, CRDP, SBP Costs). Do not include attendant-care and medical-aid payments. H. Yes No Do you receive veterans pay and benefits from the Department of Veterans Affairs that is nontaxable? If yes, report that income here. If the benefit is for attendant-care/medical-aid payments, service-connected disability compensation, or dependency & indemnity (DIC) compensation report here $. I. Yes No Do you receive Social Security or Railroad Retirement Benefits, or, income from these sources that was not included in your AGI? If yes, report that income here. (Ex: Your gross Social Security benefit was $10,000 and $4,000 was included in AGI as the taxable amount, report the non-taxable $6,000 here.) J. Yes No Do you receive income from business, rental, or farming activities (IRS Schedules C, E, or F) that was not reported on a tax return? Report that income here. You can deduct normal expenses, except depreciation expense, but do not use losses to offset income. K. Yes No Do you receive any Other Income not included in the amounts listed above? Give source, type, and amount. Do you have any of the following Allowable Deductions? L. Yes No Nursing Home, Boarding Home, or Adult Family Home costs. M. Yes No In-Home Care expenses. See instructions for qualifying expenses. N. Yes No Prescription Drug costs ONLY. Subtotal Income: $ O. Yes No Medicare Insurance Premiums ONLY (Parts B, C, and D). Cannot deduct for supplemental/medigap, long-term care, or other types of insurance premiums. P. Yes No Enter -0- here if you filed a return with IRS and entered an amount on Line A above. If you did not file a return with IRS and you had expenses normally allowed by IRS as deductions to AGI, enter those deductions here. See instructions. Subtotal Allowable Deductions: $ Total Combined Disposable Income: $ County Use Only: $$ Amount New Application (12/1/14) PAGE 2

DURING THE YEAR 2014 (answer all statements): Yes / No I sold real property and/or manufactured home during the application/income year Provide address and/or parcel number(s) Yes / No I own more than one parcel of real property (within the United States / Other Country) Provide address and/or parcel number(s) Other Country: Yes / No: I resided somewhere other than my primary residence for part of the calendar year. Provide details Yes / No: Are there other persons living in the home (excluding spouse/domestic partner or co-tenants) Yes / No: Do they contribute to the household expenses (rent, groceries, utilities, etc) Provide details Yes / No I file an IRS Tax Return (If Yes, Must provide a complete copy of tax return) 2014 Income Sources Please indicate if you, your spouse/domestic partner or co-tenant received any of the following: Yes / No: Earned Wages Yes / No: (Circle all that apply) Pension / Annuity / IRA distribution Yes / No: Social Security Benefits (SSA/SSDI reported on Form 1099-SSA) Yes / No: Supplemental Security Income (SSI) Yes / No: Railroad Retirement/Social Security Equivalent Benefit (RRB-1099) Yes / No: Cash and/or Food Assistance: TANF cash - $ /mo Food - $ /mo Other - $ Yes / No: Non-taxable Veteran s Disability or Pension Benefits $ /month Yes / No: Are benefits received for service-connected disability. Provide Rating Verification. Yes / No: Non-taxable Military Benefits (DFAS Account Statement CRSC, CRDP, SBP Costs) Yes / No: Non-taxable State L & I or U.S. Labor (OWCP) Worker s Compensation Yes / No: Unemployment Benefits Yes / No: (Circle all that apply) Alimony / Spousal Maintenance / Child Support Yes / No: Interest and/or Dividends Yes / No: Gambling Winnings Yes / No: Foreign Income (i.e.) Out-of-Country Pension Yes / No: Rental, Business and/or Farm Income (not reported on an IRS tax return) Attach a copy of a valid driver s license or State issued photo identification If not age 61 or better, attach valid proof of disability as required see instructions Attach a copy of Revocable/Irrevocable Trust Agreement, if any Mail or bring application packet to: KITSAP COUNTY ASSESSOR 614 DIVISION ST MS-22 PORT ORCHARD, WA 98366 Fax to: 360-337-4874 For Questions or Assistance call: 360-337-7160 or email: Lmcphee@co.kitsap.wa.us New Application (12/1/14) PAGE 3

FOR COUNTY USE ONLY: Income Year: Verified by (Name/date): Income reported is for: Applicant Applicant s Spouse / Domestic Partner Applicant s Co-Tenant(s) Other: The following documents were reviewed in determining the combined disposable income of this applicant under the provisions of RCW 84.36.383. Did Not File IRS Form 1040 IRS Form 1040A IRS Form 1040EZ IRS Transcript Report IRS Form 1040X (Amended) must include original 1040 Schedule B Interest & Ordinary Dividends Schedule C Profit & Loss From Business (sole proprietorship) Form 1116 Foreign Tax Credit (Foreign Income Sources) Form 8829 Expenses for Business Use of Your Home (Percent business use: ) Schedule D Capital Gains & Losses Schedule E Supplemental Income & Loss Form 4797 Sale of Business Property Form 8949 Sales & Other Dispositions Schedule F Profit and Loss from Farming Form 6252 Installment Sale Income Form K-1 Beneficiary s Share of Income Trust / Estate / Partnership / Other: 1099-R (list payers)(indicate if IRA): 1099-INT(list payers): 1099-DIV(list payers): 1099-B(list payers): 1099-G: Employment Security/Unemployment (List State) 1099-S: 1099-MISC(list payers):_ W-2(list payers): Railroad Retirement Benefits RRB-1099 RRB-1099-R 1099-SSA Other Proof: SSI benefit D.S.H.S. Food and/or Cash Assistance: L & I Worker s Compensation (Time loss and/or pension) US Dept. of Labor OWCP/disability pension: W2-G: Gambling Winnings Bank Statements: Other: Drivers License/Voter Registration/Passport Verification of ID Date of Birth Address Applicant Spouse/Domestic Partner Other: Expenses: Medicare Premiums 1099-SSA ( B, C, D ) Other Proof: Prescription Drug Costs: Licensed Care Facility Costs: In-Home Health Care Costs: AGI Deductions from IRS 1040: New Application (12/1/14) PAGE 4