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Iowa Department of Revenue

2004 Iowa Mobile/Manufactured/Modular Home

Owner Application For Reduced Tax Rate

Claimant’s Last Name

Claimant’s First Name

Claimant’s Birth Date

Claimant’s Social Security Number

County Number

Spouse’s First Name

Spouse’s Social Security Number

Spouse’s Last Name

Month

Day

Year

____

Street Address

City, State, Zip Code

Do Not Write In This Space

YES NO

Were you 23 years of age or older on 12/31/03?..............................................................................................

Use Whole DOLLARS Only

2003 Household Income

0 0

1. Wages, salaries, tips, etc. ________________________________________

2. In-kind assistance for housing expenses ______________________________

3. Title 19 Benefits (excluding medical benefits) __________________________

0 0

4. Social Security income __________________________________________

5. Disability income _______________________________________________

6. All pensions and annuities ________________________________________

7. Interest and dividend income ______________________________________

8. Profits from businesses and/or farming and capital gains.

If less than zero, enter 0 (see instructions) ____________________________

9. Actual money received from others living with you (see instructions) _________

10. Other income (Read instructions before making this entry) ________________

11. ADD amounts on Lines 1-10, enter here.

(If $17,771 or greater, 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.

________________________________________

_________

( ____ ) ________________________

Claimant’s Signature

Date

Claimant’s Telephone Number

For Use by County Treasurer Only

Sq. Footage ________________________________

Income

Reduced

Year of manufacture _________________________

Tax Rate

If year of manufacture is 1995 -1998,

$ 0.00

9,154.99

apply 90% factor.

9,155

10,231.99

.03

If year of manufacture is 1994 or before,

apply 80% factor.

10,232

11,308.99

.06

Regular Tax ________________________________

11,309

13,462.99

.10

Reduced Tax _______________________________

13,463

15,616.99

.13

Reimbursement _____________________________

15,617

17,770.99

.15

This claim must be filed with your County Treasurer by June 1, 2004, unless the treasurer extends the filing deadline

to September 30, 2004. The Director of Revenue may extend the time for filing through December 31,2004.

54-014a 09/17/03

Form 54-014a - Iowa Mobile/manufactured/modular Home Owner Application For Reduced Tax Rate - 2004

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