Form 54-001a - Iowa Property Tax Credit Claim - 2016
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1
2IOWA
2016 Iowa Property Tax Credit Claim
Complete all information below:
Your Name
Spouse Name
Your Social Security Number
Spouse Social Security Number
Your Birth Date (MM/DD/YY)
Spouse Birth Date (MM/DD/YY)
Street Address
City, State, ZIP
Telephone Number (
)
Answer These Questions to Determine Eligibility:
1. Are you currently an Iowa resident?.................................................................................................... Yes ☐ No ☐
If “No”, STOP. You do not qualify
2. Did you file a Property Tax Credit claim in 2015? ................................................................................. Yes ☐ No ☐
3a. Were you 65 or older as of December 31, 2015? ............................................................................... Yes ☐ No ☐
3b. Were you totally disabled and age 18 to 64, as of December 31, 2015? See instructions................... Yes ☐ No ☐
4. Were you a resident of a nursing home or care facility during 2015? See instructions ........................ Yes ☐ No ☐
If “Yes”, are you renting out your homestead to someone else? ......................................................... Yes ☐ No ☐
5a. Is there more than one owner of your homestead? ............................................................................. Yes ☐ No ☐
5b. Do any of the owners live elsewhere? ................................................................................................ Yes ☐ No ☐
If “Yes”, how many live elsewhere?
6. Was part of your home rented or used for business purposes during 2015? ...................................... Yes ☐ No ☐
If “Yes”, see instructions and enter the percentage here
%
7. Was any part of the land in your homestead tract rented during 2015? .............................................. Yes ☐ No ☐
If “Yes”, how many acres were used exclusively by you? __________________________________
2015 Total Household Income for the Entire Year (For You and Your Spouse)
Use whole dollars only
Read instructions before completing.
8... Wages, salaries, unemployment compensation, tips, etc. .................................
,
.00
,
9... In-kind assistance for housing expense. ...........................................................
.00
,
10... Title 19 benefits (excluding medical benefits). ...................................................
.00
11... Social Security income (include any Medicare premiums withheld). ..................
,
.00
12... Disability income. ..............................................................................................
,
.00
13... All pensions and annuities. ...............................................................................
,
.00
14... Interest and dividend income. ...........................................................................
,
.00
15... Profit from business and/or farming and capital gain.
If less than zero, enter 0. ..................................................................................
,
.00
16... Money received from others ..............................................................................
,
.00
,
17... Other income ....................................................................................................
.00
18... Total household income. Add amounts from lines 8-17.
If $22,360 or greater, STOP. No credit is allowed ............................................
,
.00
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. Note: You may be contacted for additional information.
Your Signature
Date
Return this form to your county treasurer on or before June 1, 2016, or, if the treasurer has extended the filing
deadline, on or before September 30, 2016. The Director of Revenue may extend the filing deadline through
December 31, 2017, for good cause.
Page 1
54-001a (7/28/15)
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