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Get IA DoR 54-130 2016

Can file only one claim, combining both incomes. If you do not live together, you may file separate claims. Other persons living together who qualify for a reimbursement may each file a claim based on their income and share of rent paid. NAME AND ADDRESS: Print your last name, first name Birthdate (MMDDYYYY): SSN: Print spouse last name, first name Birthdate (MMDDYYYY): SSN: Current mailing address (Include Apt, Lot, or Suite): City: State: ZIP: WHO IS ELIGIBLE: 1. Were you (or your spouse).

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