Form 54-130 - Iowa Rent Reimbursement Claim - 2003 Page 2
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1
2Worksheet for line 6
2003 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
,
if less than zero, enter 0
.
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
ENT
EIMBURSEMENT ROCESSING
OX
ES
OINES
Claims must be filed no later than June 1, 2004, unless the Director of Revenue
has granted an extension of the time to file through December 31, 2005.
Side 2
54-130b (06/05/03)
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