Form 54-130 - Iowa Rent Reimbursement Claim - 2000
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1
2I O WA
Iowa Rent Reimbursement Claim
d e p a r t m e n t o f R e v e n u e a n d F i n a n c e
2000
to be filed in 2001
Is this an amended claim? Yes
No
File early to receive your rent reimbursement sooner.
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
Street Address
Apt #, Lot #, Suite#, PO Box
Apt #, Lot #, Suite#
City, State, Zip Code
City, State, Zip Code
F
Do not write in this space.
ANSWER THESE QUESTIONS TO DETERMINE ELIGIBILTY:
YES NO
1. Did you file a Rent Reimbursement claim last year? _____________________________________
2. Were you 65 or older or totally disabled and 18 or older as of 12/31/00?
ATTACH PROOF OF DISABILITY ______________________________________________________
3. Were you a resident of Iowa during any part of 2000? __________________________________
F
4. Do you presently live in Iowa? ____________________________________________________
F
5. Were you a resident of a nursing home or care facility during 2000? _________________________
F
Use Whole Dollars Only
COMPLETE THE WORKSHEET ON THE REVERSE SIDE
0 0
,
6. Total household income from Line K Side 2 ________________________
.
F
7. Rental Period in Iowa from ___________ , 2000, to ____________ , 2000
0 0
,
8. Total rent paid in Iowa for 2000 _________________________________
.
F
2 3
9. Property Tax equivalency % ____________________________________________________ X .
0 0
,
10. Multiply Line 8 by Line 9
.
(NOT TO EXCEED $1,000) ___________________________
11. Reimbursement Rate from table on reverse Side 2 _________________________________ X
.
0 0
,
12. This is your reimbursement (multiply Line 10 by Line 11) ___________________
.
F
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.
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
Side 1
54-130a (7/31/00)
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