Form 54-130a - Iowa Rent Reimbursement Claim For Elderly Or Disabled Persons - 2011 Page 2
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2Iowa Rent Reimbursement Claim page 2
Worksheet for line 6, page 1, below. This worksheet must be completed.
2011 TOTAL YEARLY HOUSEHOLD INCOME: Total household income includes the income of the
claimant, the claimant’s spouse (if living together), rental assistance and any money received from
persons living with the claimant. Fill in the yearly total for each amount that you received in 2011 on the
worksheet below.
Use Whole Dollars Only
.
,
0 0
A. Wages, salaries, unemployment compensation, tips, etc. _______________
.
,
0 0
B. Rent and utilities assistance (any portion of rent or utilities paid for you). ___
.
,
0 0
C. Title 19 Benefits for housing only.
See instructions. _______________________
.
,
0 0
D. Social Security income (retirement or disability). ______________________
.
,
0 0
E. Disability income (SSI, VA, or Railroad). ____________________________
.
,
0 0
F. All pensions and annuities. _______________________________________
.
,
0 0
G. Interest and dividend income. ____________________________________
.
,
0 0
H. Profit from business and/or farming and capital gain.
See instructions. ______
.
,
0 0
I. Actual money received from others living with you.
See instructions. __________
.
,
0 0
J. Other Income (child support, alimony, FIP, welfare payments).
See instructions
.
,
0
0 0
K. ADD amounts on lines A through J. Enter here and on line 6, page 1. _____
Line K is your total household income. If Line K is over $20,905.99, STOP. You do not quality
for rent reimbursement.
Reimbursement Rate Table for Line 11, Page 1
If your total household income from line K above is:
$ 0.00
-
$10,769.99 ....... enter 1.00 on line 11, page 1
$10,770
-
$12,036.99 ....... enter 0.85 on line 11, page 1
$12,037
-
$13,303.99 ....... enter 0.70 on line 11, page 1
$13,304
-
$15,837.99 ....... enter 0.50 on line 11, page 1
$15,838
-
$18,371.99 ....... enter 0.35 on line 11, page 1
$18,372
-
$20,905.99 ....... enter 0.25 on line 11, page 1
$20,906 or greater ..................... no reimbursement allowed
Mail to:
Iowa Department of Revenue
Rent Reimbursement Processing
PO Box 10459
Des Moines IA 50306-0459
Where’s My Refund?
515-281-4966 or 800-572-3944 NOTE: Please allow 14 weeks after
filing before calling to check on your refund.
File this form by June 1, 2012.
Page 2
F 54-130b (09/30/11)
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