Form 54-130 - Iowa Rent Reimbursement Claim - 2004
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Iowa Department of Revenue
Iowa Rent Reimbursement Claim
2004
to be filed in 2005
Claimant’s Birth Date
County
Claimant’s Last Name
First Name
Claimant’s Social Security Number
/
/
Number
/
/
Spouse’s Last Name
First Name
Spouse’s Social Security Number
Month Day
Year
___
___
/
/
Mailing Address
Rental Address
Apt #, Lot #, Suite#, PO Box
Apt #, Lot #, Suite#
City, State, Zip Code
City, State, Zip Code
Do not write in this space.
ANSWER THESE QUESTIONS TO DETERMINE ELIGIBILITY:
YES NO
1. Did you file a Rent Reimbursement claim last year? _____________________________________
2a. Were you 65 or older 12/31/04? _________________________________________________
2b. Were you totally disabled and 18 or older as of 12/31/04?
Attach Proof of Disability __________
3. Were you a resident of Iowa during any part of 2004? ________________________________
4. Do you presently live in Iowa? ____________________________________________________
5. Were you a resident of a nursing home or care facility during 2004? _____________________
Use Whole Dollars Only
COMPLETE THE WORKSHEET ON THE REVERSE SIDE
0 0
,
0
6. Total household income from line K side 2 __________________________
.
7. Rental period in Iowa from __________ , 2004, to ____________ , 2004
0 0
,
8. Total rent paid in Iowa for 2004 ________________________________
.
2 3
9. Allowable percentage ________________________________________________________ X .
0 0
,
0
10. Multiply line 8 by line 9
.
(NOT TO EXCEED $1,000) ________________________
1.00
11. Reimbursement rate from table on reverse side 2 ________________________________ X
.
0 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.
Side 1
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
54-130a (08/23/04)
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Parent category: Financial