Form 54-130 - Iowa Rent Reimbursement Claim - 2002
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2I O WA
d e p a r t m e n t o f R e v e n u e a n d F i n a n c e
Iowa Rent Reimbursement Claim
2002
to be filed in 2003
File early to receive your rent reimbursement sooner.
Claimant’s Birth Date
County
Claimant’s Last Name
First Name
Claimant’s Social Security Number
/
/
Number
/
/
Spouse’s Last Name
First Name
Spouse’s Social Security Number
Month Day
Year
___
___
/
/
Mailing Address
Street Address
Apt #, Lot #, Suite#, PO Box
Apt #, Lot #, Suite#
City, State, Zip Code
City, State, Zip Code
p
Do not write in this space.
ANSWER THESE QUESTIONS TO DETERMINE ELIGIBILITY:
YES NO
1. Did you file a Rent Reimbursement claim last year? _____________________________________
2a. Were you 65 or older 12/31/02? __________________________________________________
2b. Were you totally disabled and 18 or older as of 12/31/02?
Attach Proof of Disability _____________
3. Were you a resident of Iowa during any part of 2002? __________________________________
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4. Do you presently live in Iowa? ____________________________________________________
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5. Were you a resident of a nursing home or care facility during 2002? _________________________
p
Use Whole Dollars Only
COMPLETE THE WORKSHEET ON THE REVERSE SIDE
0 0
,
6. Total household income from line K side 2 __________________________
.
p
7. Rental period in Iowa from ___________ , 2002, to ____________ , 2002
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,
8. Total rent paid in Iowa for 2002 _________________________________
.
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2 3
9. Allowable percentage _________________________________________________________ X .
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,
10. Multiply line 8 by line 9
.
(NOT TO EXCEED $1,000) ____________________________
11. Reimbursement rate from table on reverse side 2 __________________________________ X
.
0 0
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12. This is your reimbursement (multiply line 10 by line 11) ____________________
.
p
13. Name of apartment, nursing home or facility: ____________________________________________________
Landlord: Name _______________________________________ Telephone ( ______ ) ______________
Address: ______________________________________________________________________
City, State, Zip Code: ____________________________________________________________
14. I declare under penalty of perjury that I have reviewed this claim and to the best of my knowledge and belief, it is
true, correct and complete.
________________________________________
_________
_________________________________
Claimant’s Signature
Date
Preparer’s Signature
( _________ ) ___________________________
( __________ ) ___________________
Claimant’s Telephone Number
Preparer’s Telephone Number
Review your claim for accuracy. Incomplete claims and errors will delay processing of your reimbursement check.
Side 1
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
54-130a (07/25/02)
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