Fillable Printable 2011 Rent Certificate (Pdf Fillable Format)

2011 Rent Certificate (Pdf Fillable Format)

CAUTION:

Schedule H or H-EZ must be completed

and filed with this rent certificate

1 Name

2 Socialsecuritynumber

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

4 Timeyouactuallylivedherein2011

 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2011.

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

6 Name

7 Address

 Telephonenumber

 Renter(Claimant)

RentCerticate

2011

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,select“Forms.”

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.

/ /2011/ /2011

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2011 . . . . . . $ $ $ $

 b Numberofmonthsthis

  rentalunitwasrented

  tothisrenterin2011

 c Totalrentcollectedforthis

  rentalunitfor2011 . . . . . . . . . . . . . . . . . . $

 d Numberofoccupantsinthisrentalunit–

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

 e Thisrenter’sshareoftotal2011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)

 U

tilities 3a) 3b)

 O

ther 4a) 4b)

 T

otal 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2011. . . . . . . $ $ $ $

 b

 Numberofmonthsthis

  rentalunitwasrented

  tothisrenterin2011

 c Totalrentcollectedfor

  thisrentalunitfor2011 . . . . . . . . . . . . . . . . . $

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

Wisconsin “homestead” in 2011.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2011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.Anyportionofyourrentpaidthatis

notveried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

2011.

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2011,forthetimethisrenteroccupieditin2011.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2011,

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2011.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2011

(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,2011.

Line11eFillinthisrenter’sshareofthetotal2011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 .

 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