Rent Certificate Form - Wisconsin Department Of Revenue - 2013 Page 3
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A rent certificate is used to verify the rent paid to occupy a Wisconsin “homestead” in 2013 . A homestead could be a room,
apartment, mobile or manufactured home, house, farm, or nursing home room .
Instructions for Renter (Claimant)
Complete all fields except the social security number . Then give to your landlord to complete and sign . A separate rent certificate
must be completed for each homestead used to compute your credit .
If your landlord won’t sign, place a checkmark in the designated area . Complete the fields above line 1 and lines 1 to 5, and
attach a copy of each canceled check or bank money order you have to verify your rent . Any portion not verified will not be allowed .
After your landlord returns the completed rent certificate, enter your social security number and then fill in the allowable amounts
from lines 2b and 5a on Schedule H or H-EZ, as appropriate .
Attach all rent certificates to one Schedule H or H-EZ. If you claim less than 12 months of rent and/or property taxes, also attach a
note explaining where you lived for the balance of 2013 .
Instructions for Landlord/Authorized Representative
Complete a separate rent certificate for each renter (claimant) requesting one . If blank, fill in the renter’s name . Then fill in the
fields above line 1 and lines 1 to 5, sign and print your name, and return to the renter . Note: You may not charge a fee for filling
in a rent certificate .
Lines 1a and 1b If you checked “No” on line 1a, do not complete the rent certificate unless line 1b applies .
Line 3a Fill in the rent you actually collected per month for this rental unit (apartment, room, one-half of a duplex, etc .) for 2013, for
the time this renter occupied it in 2013 . Include any separate amounts the renter paid to you for items such as parking, a garage,
utilities, appliances, or furnishings . Do not include rent for a prior year or amounts you received directly from a governmental
agency through a subsidy, voucher, grant, etc ., for the unit (except amounts an agency paid as a claimant’s representative payee) .
If the monthly rent for this unit changed in 2013, use the extra columns to fill in each rate separately .
Line 3b Fill in the number of months (or partial months) each rate from line 3a applied to this renter . For partial months, fill in the
number of days rather than a fraction or a decimal .
Line 3c Fill in the total rent collected for this unit for the time occupied by this renter in 2013 (generally, multiply line 3a by 3b) .
Example: You rented a unit for $300 per month for 7 months and $325 per month for 5 months . Fill in lines 3a - 3c as follows:
300
.00
325
.00
.00
a Rent collected per month for this rental unit for 2013 . . . . . . . . . . 3a
7
5
b Number of months this rental unit was rented to this renter in 2013 . .
3,725
.00
c Total rent collected for this rental unit for 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3c
Line 3d Fill in the total number of occupants in this rental unit during the rental period . Note: Do not count the renter’s spouse or
children under age 18 as of December 31, 2013 .
Line 3e Fill in this renter’s share of the total rent from line 3c . Do not include rent paid for other renters .
Line 4 Fill in this renter’s share of the value of food and personal services (medical, laundry, transportation, counseling, grooming,
recreational, therapeutic, etc .) you provided for this rental unit . If none were provided, fill in 0 . Note: Do not include utilities,
furnishings, or appliances .
Signature Review the rent certificate to be sure that all applicable fields and lines have an entry . Sign (by hand) and date, print
your name, and return the rent certificate to the renter . Only an original signature is acceptable .
Renter Instructions for Shared Living Expenses Schedule
Complete this schedule if line 3d shows 2 or more occupants and each did not pay an equal share of the rent . You may claim only
the portion of rent that reflects the percentage of shared living expenses you paid .
Example: You paid shared living expenses as shown
Your allowable rent for occupancy only is $3,300, computed as
below . Services provided to you of $300 are filled in on
follows:
line 4 .
.00
$ 4,800
1 Total rent paid (line 1a) . . . . . . . . . . . . . . . . 1
2 Shared living expenses
$ 6,000
.00
Shared Living
Total Paid by
Amount
you paid (line 5b) . . . . . . . . 2
Expenses
All Occupants
You Paid
3 Total shared living
$ 4,800
.00
$ 4,800
.00
Rent
1a)
1b)
$ 8,000
.00
expenses (line 5a) . . . . . . . 3
2,400
.00
1,200
.00
Food
2a)
2b)
4 Divide line 2 by line 3 . Fill
75
in decimal amount . . . . . . . . . . . . . . . . . . . . 4
x .
600
.00
-0-
.00
Utilities
3a)
3b)
$ 3,600
.00
5 Multiply line 1 by line 4 . . . . . . . . . . . . . . . . . 5
200
.00
-0-
.00
Other
4a)
4b)
6 Value of food and services provided by
$ 8,000
.00
$ 6,000
.00
Total
5a)
5b)
$ 300
.00
landlord (line 4 above) . . . . . . . . . . . . . . . . . 6
7 Subtract line 6 from line 5 . This is your allowable
rent . Fill in here and on line 14a or 14c of
$ 3,300
.00
Schedule H (line 9a or 9c of Schedule H-EZ) 7
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