Fillable Printable Rent Certificate Sample Form

Rent Certificate Sample Form

OFFICIAL USE ONLY

PA Rent Certificate

PA Rent Certificate and Rental

Occupancy Affidavit

2014

PA-1000 RC (07–14)

PA Department of Revenue

Notarize:

Subscribed and sworn before me this

day of 20

x x

OCCUPANCY AFFIDAVIT

I am the claimant named above. I certify that I was unable to obtain my landlord’s signature on the PA Rent Certificate for the following reason(s):

Affidavit: I certify that I am the claimant named above. I also affirm all the

information on the above PA Rent Certificate and Occupancy Affidavit is

true, correct and complete to the best of my knowledge, information and

belief.

Claimant's Signature

Signature of Notary Public

Date

LANDLORD’S OATH: (Read carefully before signing)

I certify that the information provided on this PA Rent Certificate is true, correct and complete to the best of my knowledge, information and

belief. I further certify that – fill in the applicable oval(s).

I was required to pay 2014 property taxes on the property in which the claimant resided in 2014.

I made, or was required to make, a payment in lieu of taxes for 2014 on the property in which the claimant resided in 2014.

The property in which the claimant resided in 2014 was tax exempt.

Other names, excluding the spouse or minor children, appear on the lease.

Landlord’s Signature Date

1. Street address of the residence for which the claimant paid rent 3. Rental unit is (fill in the appropriate oval):

City, State, ZIP Code

2. Owner’s business name or landlord’s name (last, first, middle initial) if an individual

Landlord’s Address

City, State, ZIP Code

Landlord’s EIN (if applicable) and daytime telephone number

Name as shown on PA-1000 Social Security Number

You may make photocopies of this form as needed.

If filing as a renter, you must provide proof of the rent you paid. If you rented at more than one address, you must submit proof for each address.

PA RENT CERTIFICATE

Your landlord must provide all the information on Lines 1 through 8. Your landlord, or your landlord’s authorized agent, must sign this PA Rent

Certificate. If your landlord, or your landlord’s authorized agent, does not sign this PA Rent Certificate, you must complete Lines 1 through 8

and the Rental Occupancy Affidavit below. Your Rental Occupancy Affidavit must be notarized.

4. What was the amount of rent per month? (Include only the amount charged for rental.

Do not include security deposits or amounts paid for food, medicine, medical care

or personal care.) If your rental amounts changed during the year, please explain in the

space provided. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. How much of the monthly rental amount was paid or subsidized

by a governmental agency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

6. Total monthly amount of rent paid. (Subtract Line 5 from Line 4.) . . . . . . . . . . . . . . 6.

7. Number of months unit was occupied by the claimant in 2014.

(If less than 12 months, please explain in the space provided.) . . . . . . . . . . . . . . . . . . 7.

8. What was the total rent paid in 2014 by the claimant?

(Multiply Line 6 by Line 7.) Enter here and on Line 15 of the claim form. . . . . . . . . 8.

YOU MUST COMPLETE ALL LINES. IF NONE, ENTER “0”.

Explanation of Item 4.

Explanation of Item 7.

Dollars Cents

Apartment in a House Mobile Home Lot

Apartment Building Nursing Home

Boarding Home Private Home

Mobile Home Assisted Living

Personal Care Home

Building Name:

Domiciliary Care Foster Care

If Domiciliary Care or Foster Care, you must

submit a copy of your contract agreement.

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