Form 54-130 - Iowa Rent Reimbursement Claim - 2003

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Iowa Department of Revenue
Iowa Rent Reimbursement Claim
2003
to be filed in 2004
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
Rental 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.
Side 1
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
54-130a (7/31/03)

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