Form 54-130 - Rent Reimbursement Claim - 2001 Page 2
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1
2Worksheet for line 6
2001 TOTAL YEARLY HOUSEHOLD INCOME
0 0
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0 0
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0 0
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0 0
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0 0
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0 0
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0 0
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0 0
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if less than zero, enter 0
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0 0
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0 0
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0 0
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This is your total household income
REIMBURSEMENT RATE TABLE FOR LINE 11
If your total household income from Line K above is:
For assistance in completing this form, call 1-800-367-3388 or 515/281-3114.
Where’s my refund check?
Mail this form to:
OWA
EPARTMENT OF
EVENUE AND
INANCE
ENT
EIMBURSEMENT ROCESSING
OX
ES
OINES
Claims must be filed no later than June 1, 2002, unless the Director of Revenue and Finance
has granted an extension of the time to file through December 31, 2003.
Side 2
54-130b (08/02/01)
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