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Get IA DoR 54-130 2020-2023

2018 Iowa Rent Reimbursement Claim Clear Form Page 1 https //tax. iowa.gov NAME AND ADDRESS Complete using blue or black ink only. Do not use pencil* Incomplete claims will delay processing* You may be contacted for additional information* Married couples living together are considered one household and can file only one claim combining both incomes. If you do not live together you may file separate claims. Print your last name first name Birthdate MMDDYYYY SSN Print spouse last name first name Current mailing address Include unit number City State ZIP WHO IS ELIGIBLE 1. Were you or your spouse born before 1954. Yes No Include a copy of your letter that shows you are disabled from the Social Security Administration Veterans Administration your doctor or Form SSA-1099. If you answered no to both questions 1 and 2 STOP YOU DO NOT QUALIFY. 3. Did you live in Iowa during 2018 If no STOP YOU DO NOT QUALIFY. Yes 4. Do you currently live in Iowa If no STOP YOU DO NOT QUALIFY. Yes TOTAL ANNUAL HOUSEHOLD BENEFITS AND INCOME for you and your spouse even if not reported for Iowa individual income tax purposes 5. HUD Section 8 and any portion of rent or utilities paid for you. 6. Title 19 Benefits for housing only. If you lived in a nursing home or care facility contact the administrator for amount to enter on line 6. Or enter 20 of benefits if living in a nursing home or 40 if living in a care facility. 7. Gross Social Security income. Include SSI and Medicare premium withheld. 8. Gross disability income. Include SSDI VA and Railroad* Provide proof of disability. 9. Wages salaries unemployment compensation etc*. 10. All pension IRA and annuity income. Include military retirement pay. 11. Interest and dividend income. 12. Profit from business/farming/capital gain*. 13. Cash or checks received from others living with you. 14. Other benefits and income. Include child support alimony FIP children s SSI welfare payments gambling etc* 15. Total annual household benefits and income. Add lines 5 through 14. Is line 15 23 216 or more If yes STOP YOU DO NOT QUALIFY. 54-130a 06/14/18 Continue on next page RENTAL INFORMATION Complete the Statement of Rent Paid if you lived in more than one place. 17. Rental Address. The location where you lived must be subject to property tax. You are not eligible for rent reimbursement if the location or nursing home was not subject to property tax. Dates you rented in 2018 MMDDYY from to Total Iowa rent you paid at this location*. Street PO Box not allowed ZIP Landlord or Nursing Home Name Phone Number Address If you lived in more than one location complete the Statement of Rent paid for all other locations. 18. Total Iowa rent you paid in 2018. Add rent for all locations. THIS SECTION OPTIONAL Complete lines 19 to 21 below or allow the department to compute for you. 19. Rent eligible for reimbursement. Multiply line 18 by 0. 23 enter result. If more than 1 000 enter 1 000. Example if line 18 3 900 multiply 3 900 x 0. 23 Enter 897 on line 19 X 20. Select rate from table below based on total benefits and income on line 15.

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