Form 54-001 - Iowa Property Tax Credit Claim - 2004
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1
2Iowa Department of Revenue
Iowa Property Tax Credit Claim
To be filed in 2004
Claimant’s Last Name
First Name
Claimant’s Social Security Number
Claimant’s Birth Date
County
/
/
Number
/
/
Spouse’s Last Name
First Name
Spouse’s Social Security Number
Month Day
Year
___
___
/
/
Street Address
City, State, Zip Code
p
Do not write in this space.
ANSWER THESE QUESTIONS TO DETERMINE ELIGIBILITY:
YES NO
1. Did you file a Property Tax Credit claim last year? ______________________________________
2a. Were you 65 or older as of 12/31/03? ______________________________________________
2b. Were you totally disabled and age 18 to 64, as of 12/31/03? Attach Proof of Disability
______
3. Are you an Iowa resident? ________________________________________________________
4. Were you a resident of a nursing home or care facility during 2003? _________________________
If yes, are you renting out your homestead to someone else? ______________________________
5a. Is there more than one owner of your homestead? _____________________________________
5b. Do any of the owners live elsewhere? ______________________________________________
6. Was part of your home rented or used for business purposes during 2003? ___________________
If yes, see instructions and enter the percentage used for your home here: ___________________ %
Adjust line J accordingly.
7. Was any part of the land in your homestead tract rented during 2003? _______________________
If yes, ask your county treasurer to complete the schedule on the reverse side.
2003 Household Income (Claimant and Spouse)
Use Whole DOLLARS Only
00
8. Wages, salaries, tips, etc. _______________________________________
00
9. In-kind assistance for housing expense _____________________________
00
10. Title 19 Benefits (excluding medical benefits) _________________________
00
11. Social Security income (include any Medicare premiums withheld) _________
00
12. Disability income ______________________________________________
00
13. All pensions and annuities _______________________________________
00
14. Interest and dividend income _____________________________________
15. Profit from business and/or farming and capital gains.
00
If less than zero, enter 0. See instructions ____________________________
00
16. Actual money received from others living with you. See instructions. ________
00
17. Other income (read instructions before making this entry). _______________
18. ADD amounts on lines 8-17, and enter here. If $17,771 or greater,
00
no credit is allowed. This is your total household income. ________________
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.
_____________
(______)______________
___________________________________________
Date
Telephone Number
Claimant’s Signature
54-001a (09/18/03)
Side 1
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