Form 54-130a - 2015 Iowa Rent Reimbursement Claim Page 2
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22015 Iowa Rent Reimbursement Claim, page 2
18. Did you live in a Nursing Home or Care Facility? .............................. Yes
No
19. Landlord’s Name (or name of nursing home):
20. Landlord’s Address, City, State, ZIP:
21. Landlord’s phone number:
(
)
22. Total Iowa rent you paid in 2015 for all locations .......................................
,
.00
THIS SECTION OPTIONAL:
23. Rent allowed for reimbursement.
,
.00
Multiply line 22 by 0.2 3 a nd en te r r es u lt . ..........
If more than 1000, enter 1000 on line 23.
Example: if line 22 = 3,900, multiply 3,900 x 0.23 = Enter 897 on line 23
24. Select rate from table below based on total benefits and income on line 15:
X
.
$0.00
-
$11,518.99 ....... enter 1.00
$16,940 -
$19,649.99 ....... enter 0.35
$11,519 -
$12,873.99 ....... enter 0.85
$19,650 -
$22,359.99 ....... enter 0.25
$12,874 -
$14,228.99 ....... enter 0.70
$22,360 or greater....STOP; you do not qualify.
$14,229 -
$16,939.99 ....... enter 0.50
25. Estimated reimbursement. Multiply line 23 by line 24. .................................
,
.00
Example: line 23 = 897, multiply 897 by 0.70 = Enter 628 on line 25
DIRECT DEPOSIT INFORMATION:
Direct deposit is a fast, simple, safe, and secure way to have your reimbursement deposited into your
checking or saving account. If you wish to receive a paper check in the mail, leave lines A, B and C blank.
Yes
No
A.
Will the refund be deposited into an account outside of the United States?
B.
Routing Number:
Type: Checking
Savings
C.
Account Number:
REMINDERS:
Complete using blue or black ink, and sign the rent reimbursement form.
Married couples living together are considered one household and can file only one claim, combining
both incomes. If you do not live together, you may file separate claims. Other persons living together
who qualify for a reimbursement may each file a claim based on their income and share of rent paid.
Allow 3 months for processing. You may be contacted for additional information.
To check the status of a refund call 1-800-572-3944.
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.
If deceased,
Your signature:
Date:
date of death:
If deceased,
Spouse signature:
Date:
date of death:
Preparer signature:
Date:
Mail to: Rent Reimbursement, Iowa Department of Revenue, PO Box 10459, Des Moines, IA 50306-0459.
54-130b (06/18/15)
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