Fillable Pa Rent Certificate Template - 2016 printable pdf download

16 521

PA Rent Certificate

PA Rent Certificate and Rental

Occupancy Affidavit

PA-1000 RC (08-16)

PA Department of Revenue

OFFICIAL USE ONLY

2016

START

Name as shown on PA-1000

Social Security Number

You may make photocopies of this form as needed.

If filing as a renter, you must provide proof of the rent you paid. If you rented at more than one address, you must submit proof for each address.

PA RENT CERTIFICATE

Your landlord must provide all the information on Lines 1 through 8. Your landlord, or your landlord’s authorized agent, must sign this PA Rent

Certificate. If your landlord, or your landlord’s authorized agent, does not sign this PA Rent Certificate, you must complete Lines 1 through 8

and the Rental Occupancy Affidavit below. Your Rental Occupancy Affidavit must be notarized.

1. Street address of the residence for which the claimant paid rent

3. Rental unit is (fill in the appropriate oval):

Apartment in a House

Mobile Home Lot

City, State, ZIP Code

Apartment Building

Nursing Home

Boarding Home

Private Home

2. Owner’s business name or landlord’s name (last, first, middle initial) if an individual

Mobile Home

Assisted Living

Personal Care Home

Landlord’s Address

Building Name:

City, State, ZIP Code

Domiciliary Care

Foster Care

Landlord’s EIN (if applicable) and daytime telephone number

If Domiciliary Care or Foster Care, you must

submit a copy of your contract agreement.

YOU MUST COMPLETE ALL LINES. IF NONE, ENTER “0”.

Dollars

Cents

Explanation of Item 4.

4. What was the amount of rent per month? (Include only the amount charged for rental.

Do not include security deposits or amounts paid for food, medicine, medical care

or personal care.) If your rental amounts changed during the year, please explain in the

space provided. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. How much of the monthly rental amount was paid or subsidized

by a governmental agency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

6. Total monthly amount of rent paid. (Subtract Line 5 from Line 4.) . . . . . . . . . . . . . . 6.

Explanation of Item 7.

7. Number of months unit was occupied by the claimant in 2016.

(If less than 12 months, please explain in the space provided.) . . . . . . . . . . . . . . . . . . 7.

8. What was the total rent paid in 2016 by the claimant?

(Multiply Line 6 by Line 7.) Enter here and on Line 15 of the claim form. . . . . . . . . 8.

LANDLORD’S OATH: (Read carefully before signing)

I certify that the information provided on this PA Rent Certificate is true, correct and complete to the best of my knowledge, information and

belief. I further certify that – fill in the applicable oval(s).

I was required to pay 2016 property taxes on the property in which the claimant resided in 2016.

I made, or was required to make, a payment in lieu of taxes for 2016 on the property in which the claimant resided in 2016.

The property in which the claimant resided in 2016 was tax exempt.

Other names, excluding the spouse or minor children, appear on the lease.

Please sign and date after printing.

Landlord’s Signature

Date

OCCUPANCY AFFIDAVIT

I am, or am filing on behalf of, the claimant named above. I certify that I was unable to obtain the landlord’s signature on the PA Rent Certificate

for the following reason(s):

Affidavit: I certify that I am, or am filing on behalf of, the claimant named

Notarize:

above. I also affirm all the information on the above PA Rent Certificate

Subscribed and sworn before me this

and Occupancy Affidavit is true, correct and complete to the best of my

knowledge, information and belief.

day of

Claimant's Signature. Please sign after printing.

Signature of Notary Public. Please sign after printing.

Claimant's Signature

Date

Signature of Notary Public

MM/DD/YY

16 521

1605210051

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Pa Rent Certificate Template - 2016

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