Form 54-132 - Statement Of Rent Paid

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Statement of Rent Paid
https://tax.iowa.gov
Complete this form if you lived in more than one location. Use as many sheets as necessary. Submit
a copy along with your Iowa Rent Reimbursement claim.
Your last name, first name:
Your Social Security Number:
Rental Address. (The location where you lived must be subject to property tax. You are not eligible for
rent reimbursement if the location or nursing home was not subject to property tax.)
Dates you rented
:
from
to
(MMDDYY)
Total Iowa rent you paid at this location .....................................................
,
.00
Street (PO Box not allowed):
_______________________________________________________
City:
___________________________________________
State:
ZIP:
Landlord or Nursing Home:
Name:
__________________________________________
Phone Number:
(
)
Address:
______________________________________________________________________
City:
___________________________________________
State:
____________
ZIP:
______
Dates you rented
:
from
to
(MMDDYY)
Total Iowa rent you paid at this location .....................................................
,
.00
Street (PO Box not allowed):
_______________________________________________________
City:
___________________________________________
State:
ZIP:
Landlord or Nursing Home:
Name:
__________________________________________
Phone Number:
(
)
Address:
______________________________________________________________________
City:
___________________________________________
State:
____________
ZIP:
______
Dates you rented
:
from
to
(MMDDYY)
Total Iowa rent you paid at this location .....................................................
,
.00
Street (PO Box not allowed):
_______________________________________________________
City:
___________________________________________
State:
ZIP:
Landlord or Nursing Home:
Name:
__________________________________________
Phone Number:
(
)
Address:
______________________________________________________________________
City:
___________________________________________
State:
____________
ZIP:
______
54-132 (08/03/17)

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