Form 54-130 - Iowa Rent Reimbursement Claim - 1999
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1IOWA RENT REIMBURSEMENT CLAIM
1999
File by February 15 to receive your rent reimbursement sooner.
t
o be filed in 2000
Is this an amended claim? Yes
No
First Name
Claimant's Social Security Number
Claimant's Last Name
Claimant's Birth Date
County
Number
Spouse's Last Name
Spouse's Social Security Number
First Name
Month Day Year
Street Address
Mailing Address
City, State, Zip Code
Do not write in this space
Yes No
ANSWER THESE QUESTIONS TO DETERMINE ELIGIBILITY:
1. Did you file a Rent Reimbursement claim last year?
2. Were you 65 or older or totally disabled and 18 or older as of 12/31/99?
ATTACH PROOF OF DISABILITY
3. Were you a resident of Iowa during any part of 1999?
4. Do you presently live in Iowa?
5. Were you a resident of a nursing home or care facility during 1999?
COMPLETE THE WORKSHEET ON THE REVERSE SIDE
0 0
6. Total household income from Line K Side 2
,
.
7. Rental Period in Iowa from
, 1999 to
, 1999
0 0
8. Total rent paid in Iowa for 1999.
,
.
2 3
9. Property Tax equivalency %
X
.
0 0
10. Multiply Line 8 by Line 9 (NOT TO EXCEED $1,000.)
,
.
X
11. Reimbursement Rate from table on reverse Side 2.
.
0 0
12. This is your reimbursement (multiply Line 10 by Line 11).
,
.
13. Name of apartment, nursing home or facility
Landlord:
Name
Telephone (
)
Address
City, State, Zip Code
14. 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
Preparer's Signature
(
)
(
)
Claimant's Telephone Number
Preparer's Telephone Number
Review your claim for accuracy. Incomplete claims and errors will delay processing of your reimbursement check.
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
Side 1
54-130 (8/99) cu
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