2011 Rent Certificate Template (Page 3 of 3) in pdf

Rent Certificate Instructions

A rent certificate is used to verify the rent paid to occupy a

Example: You rented this unit for $300 per month for 7 months and

Wisconsin “homestead” in 2011. A homestead could be a

$325 per month for 5 months. Fill in lines 11a - 11c as follows:

room, apartment, mobile or manufactured home, house, farm,

a Rent collected per

or nursing home room.

month for this rental

300

325

unit for 2011 . . . . . . . $

b Number of months this

rental unit was rented

Instructions for Renter (Claimant)

to this renter in 2011

c Total rent collected for

Complete lines 1, 3, and 4. Then give the rent certificate to

3,725

this rental unit for 2011 . . . . . . . . . . . . . . . . . $

your landlord to complete lines 6 to 13 and sign. A separate

rent certificate must be completed for each homestead you

Line 11d Fill in the total number of occupants in this rental unit

rented in 2011 if used in computing your homestead credit.

during the rental period. Note: Do not count the renter’s spouse

or children under age 18 as of December 31, 2011.

If your landlord will not sign your rent certificate, check

the box on line 5. Complete lines 2 and 6 to 13, and attach

Line 11e Fill in this renter’s share of the total 2011 rent paid. Do

a copy of each canceled check or money order receipt you

not include rent paid for other renters, or amounts you received

have to verify your rent. Any portion of your rent paid that is

directly from a governmental agency (except amounts an agency

not verified will not be allowed.

paid as a claimant’s representative payee).

Line 12 Fill in this renter’s share of the value of food, medical,

After you receive the completed rent certificate from your

and other personal services, including laundry, transportation,

landlord, complete line 2 and then fill in the allowable amounts

counseling, grooming, recreational, and therapeutic services, you

from lines 10b and 13a on lines 13, 14a, and 14c of Sched-

provided for this rental unit. Do not include utilities, furnishings, or

ule H (lines 8, 9a, and 9c of Schedule H-EZ), as appropriate.

appliances. If you did not provide any of the items, fill in 0.

Note: If line 11d is 2 or more, see “Renter Instructions for

Shared Living Expenses Schedule” in the next column.

Signature Review the rent certificate to be sure that line 1 and

each of the lines 6 to 13b (and 13c, if applicable) has an entry. Sign

Attach all rent certificates to one Schedule H or H-EZ. If you

(by hand), date, and return the rent certificate to the renter. Signa-

claim less than 12 months of rent and/or property taxes, also

ture stamps, photocopied signatures, etc., are not acceptable.

attach a note explaining where you lived for the balance of

2011.

Renter Instructions for Shared Living Expenses Schedule

Instructions for Landlord /Authorized Representative

Complete this schedule if line 11d shows more than one occupant

and each occupant did not pay an equal share of the rent. You

Fill in a separate rent certificate for each renter (claimant)

may claim only the portion of rent that reflects the percentage of

requesting one for homestead credit. Fill in line 1 if it is not

shared living expenses you paid.

already completed. Fill in lines 6 to 13, sign, and give the

completed rent certificate to the renter. Note: You may not

Example: You and your roommate paid shared living expenses

charge a fee for filling in a rent certificate.

as shown below. Your landlord provided services and filled in $300

as your share on line 12.

Line 9b If you checked “No” on line 9a, do not complete

Shared Living

Total Paid by

Amount

the rent certificate unless you are a sec. 66.1201 municipal

Expenses

All Occupants

You Paid

housing authority that makes payments in lieu of property

Rent

1a)

$4,800

1b)

$4,800

taxes. If this applies to you, check the box on line 9b.

Food

2a)

2,400

2b)

1,200

Line 11a Fill in the rent you actually collected per month for

Utilities

3a)

600

3b)

-0-

this rental unit (apartment, room, one-half of a duplex, etc.)

for 2011, for the time this renter occupied it in 2011. Include

Other

4a)

200

4b)

-0-

in the monthly rate any separate amounts the renter paid

Total

5a)

$8,000

5b)

$6,000

to you for items such as a garage, parking space, utilities,

appliances, or furnishings. Do not include rent for a prior

Your allowable rent for occupancy only is $3,300, computed as

year or amounts you received directly from a governmental

follows:

agency through a subsidy, voucher, grant, etc., for the unit

$4,800

1 Total rent paid (line 1a) . . . . . . . . . . . . . . . . . . . 1

(except amounts an agency paid as a claimant’s representa-

2 Shared living expenses

tive payee). If the monthly rent for this unit changed in 2011,

$6,000

you paid (line 5b) . . . . . . . . . . 2

use the extra columns to fill in each monthly rate separately.

3 Total shared living

$8,000

Line 11b Fill in the number of months (or partial months)

expenses (line 5a) . . . . . . . . . . 3

you rented the unit to this renter in 2011. If you filled in more

4 Divide line 2 by line 3. Fill

than one amount on line 11a, fill in the number of months or

in decimal amount . . . . . . . . . . . . . . . . . . . . . . . . 4

partial months each rate applied. For partial months, fill in the

$3,600

5 Multiply line 1 by line 4 . . . . . . . . . . . . . . . . . . . . 5

number of days rather than a fraction or a decimal.

6 Value of food and services provided by

$ 300

landlord (line 12 above). . . . . . . . . . . . . . . . . . . . 6

Line 11c Fill in the total rent collected for this unit for the

period of time the unit was occupied by this renter in 2011

7 Subtract line 6 from line 5. This is your allowable

rent. Fill in here and on line 14a or 14c of

(generally, multiply line 11a by 11b).

$3,300

Schedule H (line 9a or 9c of Schedule H-EZ) . . . 7

2011 Rent Certificate Template Page 3

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