Rent Certificate - Wisconsin Department Of Revenue - 2015 Page 2
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Rent Certificate
2015
Wisconsin Department of Revenue
NOTE: • Attach to Schedule H or H-EZ
• Alterations (whiteouts, erasures, etc.) or errors void this
rent certificate.
Renter (Claimant) – Enter Social Security Number AFTER your landlord fills in section below and signs.
Legal last name
Legal first name
M.I.
Social security number
Address of rental property (property must be in Wisconsin)
City
State
Zip
2015
2015
Time you actually lived at this address in 2015
From
To
M
M
D
D
M
M
D
D
Do NOT sign your rent certificate .
If your landlord won’t sign, complete fields above and below and lines 1 to 8, attach rent verification (see instructions) , and
check here.
Landlord or Authorized Representative
Name of property owner
Telephone number
(
)
Address
City
State
Zip
1
Is the rental property a long-term care facility, CBRF or nursing home? 1
Yes
No
2 a Is the above rental property subject to property taxes?
2a
Yes
No
b If 2a is “No” and you are a sec. 66.1201 municipal housing authority
that makes payments in lieu of taxes, check here . . . . . . . . . . . . . . . . . 2b
3
Is this certificate for rent of a mobile/manufactured: a Home?
3a
Yes
No
b Home site/Lot?
3b
Yes
No
c Mobile or manufactured home taxes or municipal permit fees you collected
.00
from this renter for 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3c
.00
4 a Total rent collected for this rental unit for 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4a
.00
b If monthly rent charged didn’t change during 2015, enter monthly charge . . . . . . . . 4b
Otherwise, enter rent charged for each month below.
.00
.00
.00
.00
Jan.
Feb.
Mar.
Apr.
.00
.00
.00
.00
May
June
July
Aug.
.00
.00
.00
.00
Sept.
Oct.
Nov.
Dec.
5
Number of occupants in this rental unit – do NOT count spouse or children under 18 . . . . . . . . . . . . . . . . 5
.00
6
This renter’s share of total 2015 rent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
.00
7
Value of food and services provided by landlord (this renter’s share) . . . . . . . . . . . . . . . . 7
.00
8 a Rent paid for occupancy only – Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . 8a
b Was heat included in the rent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8b
Yes
No
I certify that the information shown on this rent certificate is true, correct, and complete to the best of my knowledge.
Signature (by hand) of landlord or authorized representative
Date
Print name (must match signature)
I-017i (R. 7-15)
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