Form 54-130 - Iowa Rent Reimbursement Claim And Total Household Income - 1998 Page 2
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1
2Worksheet for line 6
1998 TOTAL HOUSEHOLD INCOME
“Household income” includes the income of the claimant, the claimant’s spouse and
monetary contributions received from other persons living with the claimant.
Use Whole DOLLARS Only
A. Wages, salaries, tips, etc.
0 0
,
.
B. Rent subsidy/utilities assistance
0 0
,
.
C. Title 19 Benefits for housing only (see instructions)
0 0
,
.
D. Social Security income
0 0
,
.
E. Disability income
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 gains
if less than zero, enter 0 (see instructions)
0 0
,
.
I. Actual money received from others living with you (see inst.)
0 0
,
.
J. Other income (read instructions before making this entry)
0 0
,
.
K. ADD amounts on lines A-J, enter here and on Line 6 Side 1
This is your total household income.
0 0
,
.
REIMBURSEMENT RATE TABLE FOR LINE 11
If your total household income from line K above is:
$ 0.00 - 8,499.99
enter 1.00 on Line 11, Side 1
8,500 - 9,499.99
enter 0.85 on Line 11, Side 1
9,500 - 10,499.99
enter 0.70 on Line 11, Side 1
10,500 - 12,499.99
enter 0.50 on Line 11, Side 1
12,500 - 14,499.99
enter 0.35 on Line 11, Side 1
14,500 - 16,499.99
enter 0.25 on Line 11, Side 1
no reimbursement allowed
16,500 or greater
For assistance in completing this form, call 800-367-3388 or (515) 281-3114
"Where's My Refund?": Call 800-572-3944 or (515) 281-4966
You must provide claimant's Social Security number
and date of birth when calling.
Iowa Department of Revenue and Finance
Mail to:
Rent Reimbursement Processing
PO Box 10459
Des Moines, IA 50306-0459
Claims must be filed no later than June 1, 1999, unless the Director of Revenue and Finance
has granted an extension of the time to file through December 31, 2000.
Side 2
54-130 (9/98) cu
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