Form 54-130 - Iowa Rent Reimbursement Claim - 2007
ADVERTISEMENT
1
2Iowa Department of Revenue
Iowa Rent Reimbursement Claim
2007
to be filed in 2008
Claimant’s Last Name
First Name
Claimant’s Social Security Number
Claimant’s Birth Date
County
/
/
Number
/
/
Spouse’s Last Name
First Name
Spouse’s Social Security Number
Month
Day
Year
___
___
/
/
Current Mailing Address
2007 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 12/31/07? _________________________________________________
2b. Were you totally disabled and 18 to 64 as of 12/31/07?
Attach Proof of Disability ____________
3. Were you a resident of Iowa during any part of 2007? ________________________________
4. Do you presently live in Iowa? ___________________________________________________
5. Were you a resident of a nursing home or care facility during 2007? _____________________
Use Whole Dollars Only
COMPLETE THE WORKSHEET ON THE REVERSE SIDE
0 0
,
6. Total household income from line K side 2 _______________________
.
7. Rental period in Iowa from __________ , 2007, to ____________ , 2007
0 0
,
8. Total rent paid in Iowa for 2007 ________________________________
.
. 2 3
9. Allowable percentage ________________________________________________________ X
0 0
,
10. Multiply line 8 by line 9
.
(CANNOT BE MORE THAN $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) ____________________
.
You must provide the following rental information:
13. Name of apartment, nursing home or facility: _________________________________________________
Landlord/Manager 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 (or legal representative)
Date
Preparer’s Signature (if different than claimant)
_____________________________________
( _____ ) __________________
Title of Legal Representative, if any
Preparer’s Telephone Number
( _____ ) _________________
Review your claim for accuracy. Incomplete claims and errors
Claimant’s Telephone Number
will delay processing of your reimbursement check.
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
Side 1
54-130a (9/24/07)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial