Form 54-130 - Iowa Rent Reimbursement Claim For Elderly Or Disabled Persons - 2011
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Iowa Department of Revenue
Iowa Rent Reimbursement Claim
for Elderly or Disabled Persons
2011
to be filed in 2012
Claimant’s Last Name
First Name
Claimant’s Social Security Number
Claimant’s Birth Date
County
Number
Month
Day Year
/
/
/
/
Spouse’s Last Name
First Name
Spouse’s Social Security Number
Spouse’s Birth Date
Month
Day Year
/
/
/
/
Current Mailing Address
2011 Rental Street Address
Do not write in this space.
Apt#, Lot#, Suite#, PO Box
Apt#, Lot#, Suite#
City, State, ZIP
City, State, ZIP
Answer These Questions To Determine Eligibility:
1. Were you 65 or older as of 12/31/2011? ____________________________________
YES
NO
2. Were you totally disabled and age 18 to 64 as of 12/31/2011? __________________
YES
NO
If you answered “NO” to BOTH questions above (1 and 2), STOP. You do not qualify.
If you answered “NO” to 1 and “YES” to 2, you must attach current written proof of your disability.
3. Were you a resident of Iowa during any part of 2011? _________________________
YES
NO
If “NO,” STOP. You do not qualify.
4. Do you presently live in Iowa? ___________________________________________
YES
NO
If “NO,” STOP. You do not qualify.
5. Were you a resident of a nursing home or care facility during 2011? ______________
YES
NO
For line 6, you must complete the worksheet on page 2 of this form.
Use Whole Dollars Only
.
,
0
0 0
6. Total household income for 2011 from line K, page 2. ______________
7. Rental period in Iowa from________, 2011, to_______, 2011.
.
,
0 0
8. Total rent paid in Iowa for 2011. _______________________________
2 3
9. The allowable percentage rate is 23% . ________________________________________ X .
.
,
0
0 0
10. Multiply line 8 by line 9 and enter here. ____(cannot be more than $1,000)
.
1.00
11. Reimbursement rate from the table on page 2. ________________________________ X
.
,
0
0 0
12. Multiply line 10 by line 11. This is your reimbursement amount. __________
13. You must provide the following rental information:
Full name of apartment building, nursing home, or care facility: ________________________________
Landlord / Administrator Name: ___________________________ Telephone: (___) ____________
or Manager
Address: _____________________________________________________
City, State, ZIP: _______________________________________________
14. 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 (or legal representative)
Date
Preparer’s Signature (if different than claimant)
( _____ ) ___________________
____________________
( _____ ) ______________________
Claimant’s Telephone Number
Title if Representative
Preparer’s Telephone Number
Incomplete claims and errors will delay processing of your reimbursement check.
IT MAY TAKE AS LONG AS 14 WEEKS TO PROCESS YOUR CLAIM.
Page 1
54-130a (11/01/11)
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