Fillable Printable Rent Certificate - Wisconsin
Fillable Printable Rent Certificate - Wisconsin
Rent Certificate - Wisconsin
CAUTION:
Schedule H or H-EZ must be
completed and filed with this rent
certificate
Do NOT sign your rent certicate.
If your landlord won’t sign, complete elds above and below and lines 1 to 8, attach rent verication
(see instr uctions), and
check here.
Rent Certicate
2014
Wisconsin Department of Revenue
I-017i (R. 10-14)
NOTE: • Attach to Schedule H or H-EZ
• Alterations (whiteouts, erasures, etc.) or errors void this
rent certicate.
Time you actually lived at this address in 2014 From 2014 To 2014
Renter (Claimant) – Enter Social Security Number AFTER your landlord lls in section below and signs.
Legal last name
Address of rental property (property must be in Wisconsin) City State Zip
Social security numberLegal rst name M.I.
M M D D M M D D
Landlord or Authorized Representative
Name of property owner
Address City State Zip
Telephone number
( )
1 Is the rental property a long-term care facility, CBRF or nursing home? 1 Yes No
2 a Is the above rental property subject to property taxes? 2a Yes No
b If 2a is “No” and you are a sec. 66.1201 municipal housing authority
that makes payments in lieu of taxes, check here ................. 2b
3 Is this certicate for rent of a mobile/manufactured: a Home? 3a Yes No
b Home site/Lot? 3b Yes No
c Mobile or manufactured home taxes or municipal permit fees you collected
from this renter for 2014 ................................................... 3c
4 a Total rent collected for this rental unit for 2014 ................................. 4a
b If monthly rent did not change during the year, go to line 5.
Otherwise, enter monthly amounts below.
.00
5 Number of occupants in this rental unit – do NOT count spouse or children under 18 ................ 5
6 This renter’s share of total 2014 rent ......................................... 6
7 Value of food and services provided by landlord (this renter’s share) ................ 7
8 a Rent paid for occupancy only – Subtract line 7 from line 6 ........................ 8a
b Was heat included in the rent? ................................ 8b Yes No
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.00
.00
Signature (by hand) of landlord or authorized representative Date Name of landlord or authorized representative (print)
I certify that the information shown on this rent certificate is true, correct, and complete to the best of my knowledge.
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Jan.
May
Sept.
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.00
Feb.
June
Oct.
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.00
Mar.
July
Nov.
.00
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.00
Apr.
Aug.
Dec.
- 2 -
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 7 of page 1) ............. 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
Step 3: Using the amounts listed in Step 2, compute your allowable
rent paid for occupancy only:
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.00
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.00
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:
1b)
2b)
3b)
4b)
5b)
Shared Living
Expenses
Rent
1a)
Food
2a)
Utilities
3a)
Other
4a)
Total
5a)
Amount
You Paid
Total Paid by
All Occupants
.00 .00
.00
.00
.00
.00
.00
.00
.00
.00
Shared Living Expenses Schedule
– To be completed by renter only if line 5 on page one is 2 or more and each occupant
did not pay an equal share of the living expenses.
2014
Rent Certicate
Page 2 of 2
Name SSN
Instructions for Renter (Claimant)
Complete all elds except the social security number. Then
give to your landlord to complete and sign.
If your landlord won’t sign, place a checkmark in the
designated area. Complete the “Landlord or Authorized
Representative” section, and attach a copy of each
canceled check or bank money order you have to verify
your rent. Any portion not veried will not be allowed.
After your landlord returns the completed rent certicate,
enter your social security number and then ll in the
allowable amounts from lines 3c and 8a on Schedule H or
H-EZ, as appropriate.
Instructions for Landlord/Authorized Representative
Lines 2a and 2b If you checked “No” on line 2a, do not
complete the rent certicate unless line 2b applies.
Line 4a Fill in the total rent collected for this unit for the
time occupied by this renter in 2014. Include any separate
amounts the renter paid to you for items such as parking, a
garage, 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
representative payee).
Line 7 Fill in this renter’s share of the value of food
and personal services (medical, laundry, transportation,
counseling, grooming, recreational, therapeutic, etc.) you
provided for this rental unit.
Signature Review the rent certicate to be sure that all
applicable elds and lines have an entry. Sign (by hand) and
date, print your name, and return the rent certicate to the
renter. Only an original signature is acceptable.
Address of rental property
