Rent Certificate - Wisconsin Department Of Revenue - 2015 Page 3
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Renter’s
Renter’s
2015
Rent Certificate
name
SSN
2
2
Page
of
Address of rental property
Shared Living Expenses Schedule
– To be completed by renter only if line 5 on page one is 2 or more and each occupant
did not pay an equal share of the living expenses.
Step 1: List name(s) of other occupants:
Step 3: Using the amounts listed in Step 2, compute your allowable
rent paid for occupancy only:
.00
1 Total rent paid (line 1a) . . . . . . . . . . . . . . 1
2 Shared living expenses
.00
you paid (line 5b) . . . . . . . 2
Step 2: List the total amount (not the monthly amount) of
all shared living expenses (rent, food, utilities, and other)
3 Total shared living
paid by all occupants and the amount that you paid:
.00
expenses (line 5a) . . . . . . 3
Shared Living
Total Paid by
Amount
4 Divide line 2 by line 3. Fill
Expenses
All Occupants
You Paid
in decimal amount . . . . . . . . . . . . . . . . . . 4
x .
.00
.00
Rent
1a)
1b)
.00
5 Multiply line 1 by line 4 . . . . . . . . . . . . . . . 5
.00
.00
Food
2a)
2b)
6 Value of food and services provided by
.00
landlord (line 7 of page 1) . . . . . . . . . . . . . 6
.00
.00
Utilities
3a)
3b)
7 Subtract line 6 from line 5. This is your
.00
.00
Other
4a)
4b)
allowable rent. Fill in here and on
line 14a or 14c of Schedule H
.00
.00
Total
5a)
5b)
.00
(line 9a or 9c of Schedule H-EZ) . . . . . . . 7
Instructions for Renter (Claimant)
Instructions for Landlord/Authorized Representative
Complete all fields in the “Renter (Claimant)” section except
Lines 2a and 2b If you checked “No” on line 2a, do not
the social security number. Then give to your landlord to
complete the rent certificate unless line 2b applies.
complete and sign.
Line 4a Fill in the total rent collected for this unit for the time
If your landlord won’t sign, place a checkmark in the
occupied by this renter in 2015. Include any separate amounts
designated area. Complete the “Landlord or Authorized
the renter paid to you for items such as parking, a garage,
Representative” section, and attach a copy of each
utilities, appliances, or furnishings. Do not include rent for a
canceled check or bank money order you have to verify
prior year, late fees, or amounts you received directly from a
your rent. Any portion not verified will not be allowed.
governmental agency through a subsidy, voucher, grant, etc.,
for the unit (except amounts an agency paid as a claimant’s
After your landlord returns the completed rent certificate,
representative payee).
enter your social security number and then fill in the
allowable amounts from lines 3c and 8a (or line 7 of the
Line 5 Fill in the number of adult occupants who lived in this
above Shared Living Expenses Schedule – see instructions
rental unit during the rental period. Do not count the renter’s
below) on Schedule H or H-EZ, as appropriate.
spouse or children under age 18 as of December 31, 2015.
Line 7 Fill in this renter’s share of the value of food
Renter Instructions for Shared Living Expenses
and personal services (medical, laundry, transportation,
Schedule
counseling, grooming, recreational, therapeutic, etc.) you
Complete this schedule if line 5 of the rent certificate shows
provided for this rental unit.
2 or more and each occupant did not pay an equal share of
Signature Review the rent certificate to be sure that all
the living expenses.
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.
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Parent category: Financial