Form 54-130 - Rent Reimbursement Claim - 2001
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1
2I O WA
Iowa Rent Reimbursement Claim
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
2001
to be filed in 2002
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
ATTACH PROOF OF DISABILITY ______________________________________________________
p
p
p
COMPLETE THE WORKSHEET ON THE REVERSE SIDE
0 0
,
.
p
0 0
,
.
p
2 3
X .
0 0
,
.
(NOT TO EXCEED $1,000) ___________________________
.
X
0 0
,
.
p
penalty of perjury
Review your claim for accuracy. Incomplete claims and errors will delay processing of your reimbursement check.
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
Side 1
54-130a (08/02/01)
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