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Iowa Department of Revenue

2009 Iowa Mobile/Manufactured/Modular Home

Owner Application For Reduced Tax Rate

Claimant’s Last Name

Claimant’s First Name

Claimant’s Social Security Number

Claimant’s Birth Date

County Number

Spouse’s First Name

Spouse’s Social Security Number

Spouse’s Last Name

Month

Day

Year

____ ____

Street Address

City, State, Zip Code

Do Not Write In This Space

YES NO

Were you 23 years of age or older on

12/31/08?. .............................................................................

2008 Household Income

Use Whole DOLLARS Only

0 0

1. Wages, salaries, tips, etc. _______________________________________

2. In-kind assistance for housing expenses ____________________________

3. Title 19 Benefits (excluding medical benefits) _______________________

0 0

4. Social Security income _________________________________________

5. Disability income _____________________________________________

6. All pensions and annuities ______________________________________

7. Interest and dividend income ____________________________________

8. Profits from businesses and/or farming and capital gains.

If less than zero, enter 0 (see instructions) __________________________

9. Actual money received from others living with you (see instructions) ____

10. Other income (Read instructions before making this entry) _____________

11. ADD amounts on Lines 1-10, enter here.

(If $20,031 or greater, no credit is allowed) _____________________

This is your total household income.

I declare under penalty of perjury that I have reviewed this claim and to the best of my knowledge and belief,

it is true, correct and complete.

________________________________________

_________

( ____ ) ________________________

Claimant’s Signature

Date

Claimant’s Telephone Number

For Use by County Treasurer Only

Income

Reduced

Sq. Footage ________________________________

Tax Rate

Year of manufacture _________________________

If year of manufacture is 2000 -2003,

$ 0.00

10,318.99

apply 90% factor.

10,319

11,532.99

.03

If year of manufacture is 1999 or before,

apply 80% factor.

11,533

12,746.99

.06

Regular Tax ________________________________

12,747

15,174.99

.10

Reduced Tax _______________________________

15,175

17,602.99

.13

Reimbursement _____________________________

17,603

20,030.99

.15

This claim must be filed with your county treasurer by June 1, 2009, unless the treasurer extends the filing deadline

to September 30, 2009. The Director of Revenue may extend the time for filing through December 31, 2009.

54-014a (9/4/08)

Form 54-014a - Iowa Mobile/manufactured/modular Home Owner Application For Reduced Tax Rate - Iowa Department Of Revenue - 2009

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