Form 54-130a - Iowa Rent Reimbursement Claim - 2016 Page 2
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1
22016 Iowa Rent Reimbursement Claim
Page 2
RENTAL INFORMATION Complete the Statement of Rent Paid if you lived in more than one place.
16. Did you live in a Nursing Home or Care Facility?
Yes
No
17. Dates you rented in 2016 (MMDDYY): ........ from
to
Iowa rent you paid at this location .............................................................
,
.00
18. Rental Address (PO Box not allowed).
The location where you lived must be subject to property tax.
Street (include Apt, Lot, or Suite):
___________________________________________________
City:
__________________________________________
State:
ZIP:
19. Landlord or Nursing Home Name:
20. Landlord or Nursing Home Address, City, State, ZIP:
21. Landlord or Nursing Home phone number:
(
)
22. Total Iowa rent you paid in 2016 for all locations .......................................
,
.00
THIS SECTION OPTIONAL:
23. Rent allowed for reimbursement.
,
.00
Multiply line 22 by 0.2 3 a nd en te r r es u lt . ..........
If more than 1000, enter 1000. Example: if line 22 = 3,900, multiply 3,900 x 0.23 = Enter 897 on line 23
24. Select rate from table below based on total benefits and income on line 15:
X
.
$0.00
-
$11,633.99 ....... enter 1.00
$17,109 -
$19,846.99 ....... enter 0.35
$11,634 -
$13,002.99 ....... enter 0.85
$19,847 -
$22,583.99 ....... enter 0.25
$13,003 -
$14,371.99 ....... enter 0.70
$22,584 or greater....STOP; you do not qualify.
$14,372 -
$17,108.99 ....... enter 0.50
25. Estimated reimbursement. Multiply line 23 by line 24. .................................
,
.00
Example: line 23 = 897, multiply 897 by 0.70 = Enter 628 on line 25
DIRECT DEPOSIT INFORMATION:
To receive direct deposit of your reimbursement to your account, complete lines A, B, and C.
Yes
No
A.
Will the refund be deposited into an account outside of the United States?
B.
Routing Number:
Type: Checking
Savings
C.
Account Number:
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.
If deceased,
Your signature:
Date:
date of death:
If deceased,
Spouse signature:
Date:
date of death:
Claimant Phone Number:
(
)
Preparer Phone
Number:(
)
Preparer Name:
Preparer
signature:
Date:
Mail to: Rent Reimbursement, Iowa Department of Revenue, PO Box 10459, Des Moines, IA 50306-0459.
Allow 3 months for processing. You may be contacted for additional information.
To check the status of a refund visit https://tax.iowa.gov or call 1-800-572-3944.
54-130b (06/01/16)
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