Form H - Wisconsin Homestead Credit - 2011
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H
Wisconsin
2011
Check here if
homestead credit
an amended return
Claimant’s social security number
Spouse’s social security number
Check below then fill in either the name of city,
village, or town, and the county in which you lived
at the end of 2011.
Legal first name
Claimant’s legal last name
M.I.
City
Village
Town
Spouse’s legal first name
Spouse’s legal last name
M.I.
City, village,
or town
Current home address (number and street)
Apt. no.
County of
City or post office
State
Zip code
Special
(See page 7.)
conditions
1a What was your age as of December 31, 2011?
1a Fill in age
(If you were under 18, you do not qualify for homestead credit for 2011.)
b If your spouse was age 65 or over as of December 31, 2011, check where indicated . . . . . . . . . . . . . . . . . . . . . .
1b Check here
2
Were you a legal resident of Wisconsin from 1-1-11 through 12-31-11? (If “No,” you do not qualify.) . . . . . . . . . . 2
Yes
No
3
Were you claimed or will you be claimed as a dependent on someone else’s 2011 federal income tax return?
(If “Yes” and you were under age 62 on December 31, 2011, you do not qualify.) . . . . . . . . . . . . . . . . . . . . . . . . 3
Yes
No
4a Are you now living in a nursing home? (If “Yes,” indicate the date you entered
and the
nursing home name and address
) . . . 4a
Yes
No
b If “Yes,” are you receiving medical assistance under Title XIX?
. . . . 4b
Yes
No
(If both 4a and 4b are “Yes,” you do not qualify.)
5 Did you become
married or
divorced in 2011? (If “Yes,” fill in date
; see page 16.) . . . . 5
Yes
No
6a If married for any part of 2011, did you and your spouse maintain separate homes during any part of the year?
(If “Yes,” see page 15.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6a
Yes
No
b If you and your spouse maintained separate homes while married during 2011, did either spouse notify
the other of their marital property income? (See page 15.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6b
Yes
No
Print numbers like this
Not like this
NO COMMAS; NO CENTS
Household Income
Include all 2011 income as listed below. If married, include the incomes of both spouses. See pages 7 to 11.
Wisconsin income from your 2011 income tax return. If you already filed your tax return,
7
.
attach a copy marked “Duplicate.” (See page 5, Part C.1, paragraph 3.) . . . . . . . . . . . . . . . . . . 7
00
If you or you and your spouse are not filing a 2011 Wisconsin return, fill in Wisconsin
8
taxable income on lines 8a and 8b.
.
.
.
.
+
+
a Wages
00
Interest
00
Dividends
00
= . . . 8a
00
.
00
b Other taxable income. Attach a schedule listing each income item . . . . . . . . . . . . . . . . . . . . . . . . . 8b
Nontaxable household income. Do not include amounts filled in on line 7, 8a, or 8b.
9
.
00
a Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9a
b Social security, federal and state SSI, SSI-E, SSD, and caretaker supplement payments.
.
00
Include Medicare premium deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9b
.
c Railroad retirement benefits. Include Medicare premium deductions . . . . . . . . . . . . . . . . . . . . . . . . 9c
00
.
d Pensions and annuities, including IRA, SEP, SIMPLE, and qualified plan distributions (
00
)
9d
see page 9
.
00
e Contributions to deferred compensation plans (see box 12 of wage statements, and page 9) . . . . . 9e
f Contributions to IRA, self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . . . . . . . 9f
.
00
g Interest on United States securities (e.g., U.S. Savings Bonds) and state and municipal bonds . . . 9g
.
00
h Scholarships, fellowships, grants (see page 9), and military compensation or cash benefits . . . . . . 9h
.
00
.
i Child support, maintenance payments, and other support money (court ordered) . . . . . . . . . . . . . . 9i
00
.
j Wisconsin Works (W2), county relief, kinship care, and other cash public assistance
. 9j
(see page 9)
00
.
10
Add lines 7 through 9j. Enter here and on line 11a, at the top of page 2 . . . . . . . . . . . . . . . . . . . . . 10
00
Go to Page 2
I-016i
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