Form 54-130 - Iowa Rent Reimbursement Claim - 2004 Page 2
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1
2Worksheet for line 6
2004 TOTAL YEARLY HOUSEHOLD INCOME
“Household income” includes the income of the claimant, the claimant’s spouse
and monetary contributions received from other persons living with the claimant.
Use Whole DOLLARS Only
0 0
,
A. Wages, salaries, tips, etc. ________________________________________
.
0 0
,
B. Rent subsidy/utilities assistance ____________________________________
.
0 0
,
C. Title 19 Benefits for housing only (see instructions) ____________________
.
0 0
,
D. Social Security income received in 2004 __________________________
.
0 0
,
E. Disability income for 2004 _____________________________________
.
0 0
,
F. All pensions and annuities from 2004 _____________________________
.
0 0
,
G. Interest and dividend income from 2004 __________________________
.
H. Profit from business and/or farming and capital gains
0 0
,
if less than zero, enter 0 (see instructions) ________________________
.
0 0
,
I. Actual money received from others living with you in 2004 (see instructions)
.
0 0
,
J. Other income (read instructions before making this entry) ____________
.
0 0
,
0
K. ADD amounts on lines A-J, enter here and on Line 6 Side 1 _____________
.
This is your total household income
REIMBURSEMENT RATE TABLE FOR LINE 11
If your total household income from Line K above is:
$ 0.00
-
9,290.99 -------- enter 1.00 on Line 11, Side 1
9,291
-
10,383.99 -------- enter 0.85 on Line 11, Side 1
10,384
-
11,476.99 -------- enter 0.70 on Line 11, Side 1
11,477
-
13,662.99 -------- enter 0.50 on Line 11, Side 1
13,663
-
15,848.99 -------- enter 0.35 on Line 11, Side 1
15,849
-
18,034.99 -------- enter 0.25 on Line 11, Side 1
18,035 or greater ------------------- no reimbursement allowed
For assistance in completing this form, call 1-800-367-3388 or 515/281-3114.
Where’s my refund check?
Call 1-800-572-3944 or 515/281-4966
You must provide claimant’s Social Security Number
and date of birth when calling
Mail this form to:
I
D
R
OWA
EPARTMENT OF
EVENUE
R
R
P
ENT
EIMBURSEMENT
ROCESSING
PO B
10459
OX
D
M
IA 50306-0459
ES
OINES
Claims must be filed no later than June 1, 2005, unless the Director of Revenue
has granted an extension of the time to file through December 31, 2006.
Side 2
54-130b (11/17/04)
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