Form 54-130a - 2015 Iowa Rent Reimbursement Claim
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1
2Clear Form
Iowa Department of Revenue
2015 Iowa Rent Reimbursement Claim
https://tax.iowa.gov
Page 1
Your last name, first name
Phone Number:
(
)
Birthdate
:
SSN:
(MMDDYYYY)
Spouse last name, first name
Birthdate
:
SSN:
(MMDDYYYY)
Current mailing address
(Include Apt, Lot, or Suite):
City:
State:
ZIP:
WHO IS ELIGIBLE:
1. Were you (or your spouse) born before 1951? ....................................................... Yes
No
2. Were you (or your spouse) born between 1951 and 1997 and totally disabled? .... Yes
No
Proof of disability must be included with your claim. Include a copy of letter from Social Security Administration, Veterans
Administration, your doctor, or Form SSA-1099. Totally disabled means you are unable to get a job paying more than $1,070
per month due to a physical or mental disability which has lasted, or is expected to last, for at least one year.
If you answered “no” to both questions 1 and 2, STOP; YOU DO NOT QUALIFY.
3. Did you live in Iowa during 2015? If “no,” STOP; YOU DO NOT QUALIFY. ........... Yes
No
4. Do you currently live in Iowa? If “no,” STOP; YOU DO NOT QUALIFY. ................. Yes
No
TOTAL HOUSEHOLD BENEFITS AND INCOME FOR THE ENTIRE YEAR
:
for you and your spouse
5. HUD, Section 8, and any portion of rent or utilities paid for you .................
,
.00
6. Title 19 Benefits for housing only ...............................................................
,
.00
If you lived in a nursing home or care facility, contact the administrator for amount to enter on
line 6. Or, enter 20% of benefits if living in a nursing home or 40% if living in a care facility.
7. Social Security income.
.......................
,
.00
Include SSI and Medicare premium withheld
8. Disability income.
...............
,
.00
Include SSDI, VA, and Railroad. Provide proof of disability
9. Wages, salaries, unemployment compensation, etc. ...................................
,
.00
10. All pensions and annuity income.
..........................
,
.00
Include military retirement pay
11. Interest and dividend income .......................................................................
,
.00
12. Profit from business/farming/capital gain .....................................................
,
.00
13. Cash or checks received from others ..........................................................
,
.00
14. Other benefits and income ...........................................................................
,
.00
etc.) ..............................................................................
gambling,
---------------------
Include child support, alimony, FIP, children’s SSI, welfare payments, gambling, etc.
15. Total household benefits and income.
,
.00
Add amounts on lines 5 through lines 14 .......
Is line 15 $22,360 or more? If yes, STOP; YOU DO NOT QUALIFY.
RENTAL INFORMATION
Complete the separate Statement of Rent Paid form if you lived in more than one location.
16. Dates you rented in 2015 (MMDDYY): ..........from
to
Iowa rent you paid at this location .............................................................
,
.00
17. Rental Address (PO Box not allowed).
The location where you lived must be subject to property tax.
Street (include Apt, Lot, or Suite):
___________________________________________________
City:
__________________________________________
State:
_____________________
ZIP:
Continue on back
54-130a (11/06/15)
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Parent category: Financial