Fillable Printable 2010 Rent Certificate (Pdf Fillable Format)

2010 Rent Certificate (Pdf Fillable Format)

1 Name

2 Social security number

3 Address of rental property (property must be in Wisconsin)

4 Time you actually lived here in 2010

From (mo./day) To (mo./day)

5 Ifyourlandlordwillnotsignyourrentcerticate,completelines6to13,

attachrentverication(seeinstructions),andcheckthisbox.è

10a Isthisrentcerticateforrentof:

A mobile or manufactured home? Yes No

A mobile or manufactured home site? Yes No

b Mobileormanufacturedhometaxesormunicipalpermitfees

you collected from this renter for 2010.

1 Total rent paid (line 1a) . . . . . . . . . . . . . . . . . . . 1

2 Sharedlivingexpenses

you paid (line 5b) . . . . . . . . . . 2

3 Total shared living

 expenses(line5a) . . . . . . . . . 3

4 Divideline2byline3.Fill

in decimal amount . . . . . . . . . . . . . . . . . . . . . . . 4 x .

5 Multiply line 1 by line 4 . . . . . . . . . . . . . . . . . . . . 5

6 Value of food and services provided by

landlord (line 12 above) . . . . . . . . . . . . . . . . . . . 6

7 Subtractline6fromline5.Thisisyourallowable

rent. Fill in here and on line 14a or 14c of

Schedule H (line 9a or 9c of Schedule H-EZ) . . 7

9 a Istherentalproperty(line3)subjecttopropertytaxes?

Yes No

b If9ais“No”andyouareasec.66.1201

  municipalhousingauthoritythatmakes

  paymentsinlieuoftaxes,checkthisbox.è

Name

7 Address

8 Telephone number

Renter (Claimant)

Rent Certicate

2010

Wisconsin Department of Revenue

NOTE:Alterationsonlines1to13orthesignatureline(whiteouts,erasures,etc.)willvoid this

rentcerticate.Arentcerticatewithanerrorshouldbediscardedandanewonecompleted.

Needanadditionalrentcerticate?Gotowww.revenue.wi.gov.

NEED HELP? 608‑266‑8641(Madison)or414‑227‑4000(Milwaukee) REMINDERS FOR RENTERS:

• Ifline11daboveis2ormoreandeachoccupantdid

notpayanequalshareoftherent,seeinstructions

forSharedLivingExpensesSchedule.

• ScheduleHorH‑EZmustbecompletedandled

withthisrentcerticate.

/ / 2010/ / 2010

Completelines1,3,and4.Haveyourlandlordll

inlines6to13andsign,thencompleteline2.

Landlord Fillinlines6to13andsign.

Signature (by hand) of landlord or authorized representative Date

I certify that the information shown on this rent certicate

is true, correct, and complete to the best of my knowledge.

Sign

here

11 Fill in lines 11a to 11e based on the period of time this rental

unit was occupied by this renter. Use the additional columns

on lines 11a and 11b only if rent rates changed during the year

(see instructions). Do not include amounts received directly from

a governmental agency.

a Rent collected per

month for this rental

unit for 2010 . . . . . . $ $ $ $

b Number of months this

rental unit was rented

to this renter in 2010

c Total rent collected for this

rental unit for 2010 . . . . . . . . . . . . . . . . . . $

d Number of occupants in this rental unit –

do notcountspouseorchildrenunder18. .

e This renter’s share of total 2010 rent . . . . . $

12 Value of food and services provided

by landlord (this renter’s share) . . . . . . . . . $

13a Rent paid for occupancy only –

Subtract line 12 from line 11e . . . . . . . . . . $

b Was heat included in the rent? Yes No

c Ifalong‑termcarefacility/CBRF/nursinghome,

  checkthemethodusedtocomputeline13a:

   Standardrate($100perweek).

   Percentageformula(llinpercentage) %.

Other method approved by Department of Revenue.

I‑017i

Shared Living Expenses Schedule

Step 1:Listname(s)ofotheroccupants:

Step 2:Listthetotalamount(notthemonthlyamount)of

allsharedlivingexpenses(rent,food,utilities,andother)

paidbyalloccupantsandtheamountthatyoupaid:

Shared Living

Expenses

Rent 1a) 1b)

Food 2a) 2b)

 Utilities 3a) 3b)

Other 4a) 4b)

Total 5a) 5b)

Amount

You Paid

Total Paid by

All Occupants

Step 3:UsingtheamountslistedinStep2,computeyourallow-

ablerentpaidforoccupancyonly:

Tab to navigate within form. Use mouse to check

applicable boxes, press spacebar or Enter.

Save

Clear

Tab to navigate within form. Use mouse to

check applicable boxes, press spacebar or

Enter.

Clear

Example:Yourentedthisunitfor$300permonthfor7monthsand

$325permonthfor5months.Fillinlines11a‑11casfollows:

a Rent collected per

month for this rental

unit for 2010 . . . . . .$ $ $ $

b Number of months this

rental unit was rented

to this renter in 2010

c Total rent collected for

this rental unit for 2010 . . . . . . . . . . . . . . . . . $

Arentcerticateisusedtoverifytherentpaidtooccupya

Wisconsin “homestead” in 2010. A homestead could be a

room,apartment,mobileormanufacturedhome,house,farm,

or nursing home room.

Instructions for Renter (Claimant)

Completelines1,3,and4.Thengivetherentcerticateto

yourlandlordtocompletelines6to13andsign.Aseparate

rentcerticatemustbecompletedforeachhomesteadyou

rented in 2010 if used in computing your homestead credit.

 Ifyourlandlordwillnotsignyourrentcerticate,check

theboxonline5.Completelines2and6to13,andattach

acopyofeachcanceledcheckormoneyorderreceiptyou

havetoverifyyourrent.Ifyoudonothavevericationofyour

rentpaid,thehomesteadcreditwillnotbeallowed.

After you receive the completed rent certicate from your

landlord,completeline2andthenllintheallowableamounts

fromlines10band13aonlines13,14a,and14cofSched-

uleH(lines8,9a,and9cofScheduleH‑EZ),asappropriate.

Note: If line 11d is2ormore, see“Renter Instructions for

SharedLivingExpensesSchedule”inthenextcolumn.

AttachallrentcerticatestooneScheduleHorH‑EZ.Ifyou

claimlessthan12monthsofrentand/orpropertytaxes,also

attachanoteexplainingwhereyoulivedforthebalanceof

2010.

Instructions for Landlord /Authorized Representative

Fill in a separate rent certicate for each renter(claimant)

requesting one for homestead credit. Fill in line 1 if it is not

already completed. Fill in lines 6to13, sign, and give the

completedrentcerticatetotherenter.Note:Youmaynot

chargeafeeforllinginarentcerticate.

Line 9b  If you checked “No” on line 9a, donot complete

therentcerticateunlessyouareasec.66.1201municipal

housing authority that makes payments in lieu of property

taxes.Ifthisappliestoyou,checktheboxonline9b.

Line 11a Fill in the rent you actually collected per month for

thisrentalunit(apartment,room,one‑halfofaduplex,etc.)

for2010,forthetimethisrenteroccupieditin2010.Include

in the monthly rate any separate amounts the renter paid

to youforitemssuchasagarage,parkingspace,utilities,

appliances, or furnishings. Do not include rent for a prior

year or amounts you received directly from a governmental

agencythroughasubsidy,voucher,grant,etc.,fortheunit

(exceptamountsanagencypaidasaclaimant’srepresenta-

tivepayee).Ifthemonthlyrentforthisunitchangedin2010,

usetheextracolumnstollineachmonthlyrateseparately.

Line 11b Fill in the number of months (or partial months)

yourentedtheunittothisrenterin2010.Ifyoulledinmore

thanoneamountonline11a,llinthenumberofmonthsor

partialmonthseachrateapplied.Forpartialmonths,llinthe

number of days rather than a fraction or a decimal.

Line 11c Fill in the total rent collected for this unit for the

period of time the unit was occupied by this renter in 2010

(generally,multiplyline11aby11b).

Rent Certicate Instructions

Line 11d Fill in the total number of occupants in this rental unit

during the rental period. Note

:Donotcounttherenter’sspouse

orchildrenunderage18asofDecember31,2010.

Line 11e Fill in this renter’s share of the total 2010 rent paid. Do

notincluderentpaidforotherrenters,oramountsyoureceived

directlyfromagovernmentalagency(exceptamountsanagency

paid as a claimant’s representative payee).

Line 12

Fillinthisrenter’sshareofthevalueoffood,medical,

and other personal services, including laundry, transportation,

counseling,grooming,recreational,andtherapeuticservices,you

providedforthisrentalunit.Donotincludeutilities,furnishings,or

appliances.Ifyoudidnotprovideanyoftheitems,llin0.

SignatureReviewtherentcerticatetobesurethatline1and

eachofthelines6to13b(and13c,ifapplicable)hasanentry.Sign

(byhand),date,andreturntherentcerticatetotherenter.Signa-

turestamps,photocopiedsignatures,etc.,arenotacceptable.

Renter Instructions for Shared Living Expenses Schedule

Complete this schedule if line 11d shows more than one occupant

and each occupant did not pay an equal share of the rent. You

mayclaimonlytheportionofrentthatreectsthepercentageof

sharedlivingexpensesyoupaid.

Example:Youandyourroommatepaidsharedlivingexpenses

asshownbelow.Yourlandlordprovidedservicesandlledin$300

as your share on line 12.

300 325

7 5

3,725

Shared Living

Expenses

Rent 1a) 1b)

Food 2a) 2b)

 Utilities 3a) 3b)

Other 4a) 4b)

Total 5a) 5b)

Amount

You Paid

Total Paid by

All Occupants

$4,800

2,400

600

200

$8,000

$4,800

1,200

-0-

$6,000

Your allowable rent for occupancy only is $3,300, computed as

follows:

1 Total rent paid (line 1a) . . . . . . . . . . . . . . . . . . . 1

 Sharedlivingexpenses

you paid (line 5b) . . . . . . . . . . 2

Total shared living

 expenses(line5a) . . . . . . . . . . 3

 Divideline2byline3.Fill

in decimal amount . . . . . . . . . . . . . . . . . . . . . . . . 4 x .

5 Multiply line 1 by line 4 . . . . . . . . . . . . . . . . . . . . 5

Value of food and services provided by

landlord (line 12 above). . . . . . . . . . . . . . . . . . . . 6

 Subtractline6fromline5.Thisisyourallowable

rent. Fill in here and on line 14a or 14c of

Schedule H (line 9a or 9c of Schedule H-EZ) . . . 7

$4,800

$6,000

$3,600

$300

$3,300

$8,000