Form 54-130a - Iowa Rent Reimbursement Claim For Elderly Or Disabled - 2013
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1
2Iowa Department of Revenue
2013 Iowa Rent Reimbursement Claim
for Elderly or Disabled
File on or before June 1, 2014
Reset Form
Your Last Name
Your First Name
Your Social Security Number
Your Birth Date
Month
Day
Year
Spouse’s Last Name
Spouse’s First Name
Spouse’s Social Security Number
Spouse’s Birth Date
Month
Day
Year
Your Current Mailing Address (Street, Apt #, Lot #, Suite #)
City, State, ZIP
Do not write in this space.
Your Rental Address in 2013 (PO Box not allowed) Street, Apt #, Lot #, Suite #
City, State, ZIP
before
Were you (or your spouse) born
1949? _____________________________________
1.
YES
NO
AND
2. Are you (or your spouse) totally disabled
born between 1949 and 1995?
_______________ YES
NO
Attach
(
a copy of letter from Social Security Administration, Veterans Administration, your doctor, or Form SSA-1099.)
Note: If you answered “no” to questions 1 and 2 STOP, you don’t qualify.
3. Did you live in Iowa during 2013? If “No”, STOP; no reimbursement allowed. _____________
YES
NO
4. Do you currently live in Iowa? If “No”, STOP; no reimbursement allowed. ________________
YES
NO
5. Were you in a nursing home or care facility during 2013? _____________________________
YES
NO
Use Whole Dollars Only
Total Household Income (for you and your spouse) for entire year
0 0
.
A
Wages, salaries, unemployment compensation, etc. ___________________________
,
.
0 0
B. HUD, Section 8, and any portion of rent or utilities paid for you. __________________
.
,
0 0
C
Title 19 Benefits for housing only. _________________________________________
.
,
.
0 0
D. Social Security income
.
,
(including SSI and Medicare premiums withheld). ______________________
0 0
.
E. Disability income (include SSDI, VA, Railroad).
,
(Attach proof of disability.) ________________
0 0
.
F. All pensions and annuity income. _________________________________________
,
.
0 0
G. Interest and dividend income. ____________________________________________
,
.
0 0
H. Profit from business/farming/capital gain. __________________________________
,
0 0
.
I. Cash or checks received from others. ______________________________________
,
0 0
.
J. Other Income
. _______
,
(child support, alimony, FIP, children’s SSI, welfare payments, gambling, etc)
0
0 0
.
K. ADD amounts on lines A through J. This is your total household income. _________
,
I
;
s Line K $21,698 or greater? If yes,
no rent reimbursement is allowed. If Line K is less than $21,698, continue to line 6.
STOP
6. Time you rented, from _____________________,2013 to_____________________,2013.
0 0
.
7. Total Iowa rent you paid in 2013
,
8. Name of apartment building, nursing home, or care facility:
__________________________________________________________
The owner of the place you rent must pay property tax. Landlord’s Name:_________________________________
Landlord’s Address:______________________________________________________ Phone: (____) _____________
The rent reimbursement amount will be calculated for you. To calculate your reimbursement, continue on the back.
I have reviewed this claim and believe it is correct and complete.
Sign
Print Form
(
)
Your signature (or legal representative)
Spouse Signature
Date
Daytime Phone
Here
(
)
Mail to: Rent Reimbursement, Iowa Department of Revenue
Preparer’s Signature
Phone
PO Box 10459, Des Moines, IA 50306-0459
ALLOW 3 MONTHS FOR PROCESSING
Check on refund: 1-800-572-3944
54-130a (09/11/13)
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Parent category: Financial