Worksheet for line 6
2006 TOTAL YEARLY HOUSEHOLD INCOME
“Household income” includes the income of the claimant, the claimant’s spouse
and monetary contributions received from other persons living with the claimant.
Use Whole DOLLARS Only
0 0
,
A. Wages, salaries, tips, etc. ________________________________________
.
0 0
,
B. Rent subsidy/utilities assistance ____________________________________
.
0 0
,
C. Title 19 Benefits for housing only (see instructions) ____________________
.
0 0
,
D. Social Security income received in 2006 __________________________
.
0 0
,
E. Disability income for 2006 _____________________________________
.
0 0
,
F. All pensions and annuities from 2006 _____________________________
.
0 0
,
G. Interest and dividend income from 2006 __________________________
.
H. Profit from business and/or farming and capital gains
0 0
,
if less than zero, enter 0 (see instructions) ________________________
.
0 0
,
I. Actual money received from others living with you in 2006 (see instructions)
.
0 0
,
J. Other income (read instructions before making this entry) ____________
.
0 0
,
0
K. ADD amounts on lines A-J, enter here and on Line 6 Side 1 _____________
.
This is your total household income
REIMBURSEMENT RATE TABLE FOR LINE 11
If your total household income from Line K above is:
$ 0.00
-
9,723.99 ....... enter .94 on Line 11, Side 1
IMPORTANT CHANGE
9,724
-
10,867.99 ....... enter .80 on Line 11, Side 1
Because of limited funding and the
increased number of claims filed, the
10,868
-
12,011.99 ....... enter .66 on Line 11, Side 1
reimbursement rate on line 11 is lower
for 2006 than it was in previous years.
12,012
-
14,299.99 ....... enter .47 on Line 11, Side 1
Therefore, the total amount of your
claim on line 12 may be less than you
14,300
-
16,587.99 ....... enter .33 on Line 11, Side 1
have received in the past.
16,588
-
18,875.99 ....... enter .24 on Line 11, Side 1
18,876 or greater ........................ no reimbursement allowed
For assistance in completing this form, call 1-800-367-3388 or 515/281-3114.
Where’s my refund check?
Call 1-800-572-3944 or 515/281-4966
You must provide claimant’s Social Security Number
and date of birth when calling
Mail this form to:
I
D
R
OWA
EPARTMENT OF
EVENUE
R
R
P
ENT
EIMBURSEMENT
ROCESSING
PO B
10459
OX
D
M
IA 50306-0459
ES
OINES
Side 2
54-130b (10/19/06)