*121421100*
FORM
Landlord’s Certificate
VT
142
LC-
* 1 2 1 4 2 1 1 0 0 *
CLAIMANT: Remember to enter your Social Security Number when you file the rebate claim. This schedule must be attached to the
Renter Rebate Claim OR the Property Tax Adjustment Claim.
-
-
Claimant’s Last Name
First Name
Initial
Claimant’s Social
Security Number
1. Name of owner
or landlord
Landlord’s Full Mailing Address ________________________________________________________________________________________________
2. Location of
rental unit
number, street/road name
city/town
-
-
3. SPAN
4. Enter the number of rental
(From property tax bill)
Number
units in this building
5.
6.
RENTAL UNIT IS (check type)
ITEMS INCLUDED IN RENT (Check all that apply)
Lot for
Boarding
Other
Apartment
Heat
Electricity
mobile home
home
Services
Mobile
Nursing home/
Personal
House
Furnishings
home
community care
Care
7.
List name(s) of
renters for this
rental unit during
this period
8. Calendar year . . . . . . . . . . . . 8a.
Number of months rented . . 8b.
0 0
.
9. Monthly rental amount paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.
0 0
.
10. Total Rent Paid for calendar year listed on Line 8a. . . . . . . . . . . . . . . . . . . . . . . . . . . 10.
0 0
11. Less dollar value of items checked in Box 6 above that were included in rent
.
(heat, electricity, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
0 0
.
12. Adjusted rent paid for calendar year listed on Line 8a (Line 10 minus Line 11) . . . . . 12.
%
13. For government subsidized rent, enter percent tenant pays.
.
For nonsubsidized rent, enter 100.00% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.
0 0
14. Rent Paid during calendar year solely for the right of occupancy
.
(Multiply Line 12 by Line 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.
%
2 1
0 0
.
15. Rental Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.
0 0
.
16. Allocable Rent (Multiply Line 14 by Line 15) Enter here and on Form PR-141, Line 3. . . . . . . . . . . . . . . . . . 16.
For MOBILE HOME LOT RENT, enter on Property Tax Adjustment Claim. DO NOT FILE FORM PR-141.
I certify the rental information on this Landlord’s Certificate is, to the best of my knowledge and belief, true, correct, and complete.
Signature of landlord or authorized representative
Date
Daytime Telephone Number
Form LC-142
5454
Rev. 10/12