Form Mo-Crp - Certification Of Rent Paid For 2004

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2004
• Read instructions.
• Print or type.
MISSOURI DEPARTMENT OF REVENUE
FORM
Failure to provide landlord information will
CERTIFICATION OF RENT PAID FOR 2004
MO-CRP
result in denial or delay of your claim.
1. SOCIAL SECURITY NUMBER
SPOUSE’S SOCIAL SECURITY NUMBER
ARE YOU RELATED TO YOUR LANDLORD?
YES
NO
IF YES, EXPLAIN.
2. NAME
3. LANDLORD’S NAME, SOCIAL SECURITY NO., OR FEIN
ADDRESS OF RENTAL UNIT (DO NOT LIST P.O. BOX)
LANDLORD’S ADDRESS, CITY, STATE, AND ZIP CODE (MUST BE COMPLETED)
CITY, STATE, AND ZIP CODE
4. LANDLORD’S PHONE NUMBER (MUST BE COMPLETED)
(
)
5. RENTAL PERIOD
FROM:
MONTH
DAY
YEAR
TO:
MONTH
DAY
YEAR
—
—
2004
—
—
2004
DURING YEAR
6. Enter your gross rent paid. Attach rent receipt(s) for each rent payment or the entire year, a statement from your
00
landlord, or copies of cancelled checks (front and back). If receiving assistance, enter the amount of rent YOU paid.
6
7. Check the appropriate box and enter the corresponding percentage on Line 7.
A. APARTMENT, HOUSE, MOBILE HOME, OR DUPLEX — 100%
B. MOBILE HOME LOT — 100%
C. BOARDING HOME / RESIDENTIAL CARE — 50%
D. SKILLED OR INTERMEDIATE CARE NURSING HOME — 45%
E. HOTEL If meals are included, enter — 50%; Otherwise, enter — 100%
F. LOW INCOME HOUSING — 100%
(Rent cannot exceed 40% of total household income.)
G. SHARED RESIDENCE — If you shared your rent with relatives and/or friends (other than your spouse
or children under 18), check the appropriate box and enter percentage.
%
Additional persons sharing rent/percentage to be entered:
1 (50%)
2 (33%)
3 (25%) . . . . . 7
8. Net rent paid — Multiply Line 6 by the percentage on Line 7. ENTER HERE AND IN THE BOX ON
FORM MO-PTS, LINE 12a OR FORM MO-PTC, LINE 10a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
00
For Privacy Notice, see the instructions.
MO 860-1089 (11-2004)
2004
• Read instructions.
• Print or type.
MISSOURI DEPARTMENT OF REVENUE
FORM
Failure to provide landlord information will
CERTIFICATION OF RENT PAID FOR 2004
MO-CRP
result in denial or delay of your claim.
1. SOCIAL SECURITY NUMBER
SPOUSE’S SOCIAL SECURITY NUMBER
ARE YOU RELATED TO YOUR LANDLORD?
YES
NO
IF YES, EXPLAIN.
2. NAME
3. LANDLORD’S NAME, SOCIAL SECURITY NO., OR FEIN
ADDRESS OF RENTAL UNIT (DO NOT LIST P.O. BOX)
LANDLORD’S ADDRESS, CITY, STATE, AND ZIP CODE (MUST BE COMPLETED)
CITY, STATE, AND ZIP CODE
4. LANDLORD’S PHONE NUMBER (MUST BE COMPLETED)
(
)
5. RENTAL PERIOD
FROM:
MONTH
DAY
YEAR
TO:
MONTH
DAY
YEAR
—
—
2004
—
—
2004
DURING YEAR
6. Enter your gross rent paid. Attach rent receipt(s) for each rent payment or the entire year, a statement from your
00
landlord, or copies of cancelled checks (front and back). If receiving assistance, enter the amount of rent YOU paid.
6
7. Check the appropriate box and enter the corresponding percentage on Line 7.
A. APARTMENT, HOUSE, MOBILE HOME, OR DUPLEX — 100%
B. MOBILE HOME LOT — 100%
C. BOARDING HOME / RESIDENTIAL CARE — 50%
D. SKILLED OR INTERMEDIATE CARE NURSING HOME — 45%
E. HOTEL If meals are included, enter — 50%; Otherwise, enter — 100%
F. LOW INCOME HOUSING — 100% (Rent cannot exceed 40% of total household income.)
G. SHARED RESIDENCE — If you shared your rent with relatives and/or friends (other than your spouse
or children under 18), check the appropriate box and enter percentage.
%
Additional persons sharing rent/percentage to be entered:
1 (50%)
2 (33%)
3 (25%) . . . . . 7
8. Net rent paid — Multiply Line 6 by the percentage on Line 7. ENTER HERE AND IN THE BOX ON
FORM MO-PTS, LINE 12a OR FORM MO-PTC, LINE 10a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
00
For Privacy Notice, see the instructions.
MO 860-1089 (11-2004)

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