Renter (claimant)
Rent Certificate
2006
Wisconsin Department of Revenue
NOTE: Alterations on lines 1 to 13 or the signature line (whiteouts, erasures, etc.) will void this
rent certificate. A rent certificate with an error should be discarded and a new one completed.
NEED HELP?
Contact any Department of Revenue office. Check your
phone book for local listing.
You may also call:
(608) 266-8641 (Madison)
(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 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 2006
From (mo/day) To (mo/day)
5 If your landlord will not sign your rent certificate, complete lines 6 to 13,
attach rent verification (see instructions), and check this box. ¤
/ / 2006/ / 2006
Complete lines 1 to 5. Then have your
landlord fill in lines 6 to 13 and sign.
Landlord Fill in lines 6 to 13 and sign.
10a Is this rent certificate for rent of:
A mobile home? Yes No
A mobile home site? Yes No
b Mobile home taxes or parking permit fees, or municipal fees
you collected from this renter for 2006. $
6 Name
7 Address
8 Telephone number
9a 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. ¤
Signature (by hand) of landlord or authorized representative Date
I certify that the information shown on this rent certificate 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 2006. $ $ $ $
b Number of months this
rental unit was rented
to this renter in 2006.
c Total rent collected for this
rental unit for 2006. $
d Number of occupants in this rental unit –
do not count spouse or children under 18.
e This renter’s share of total 2006 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 (fill in percentage) %.
Other method approved by Department of Revenue.
I-017
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 allowable
rent paid for occupancy only:
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
Tab to navigate within form. Use mouse to check
applicable boxes, press spacebar or Enter.
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Tab to navigate within form. Use mouse to
check applicable boxes, press spacebar or
Enter.
Print
Clear
A rent certificate is used to verify the rent paid to occupy a
Wisconsin "homestead" in 2006. A homestead could be a
room, apartment, mobile home, house, farm, or nursing home
room.
Instructions for Renter (Claimant)
Complete lines 1 to 5. Then give the rent certificate to your
landlord to complete lines 6 to 13 and sign. A separate rent
certificate must be completed for each homestead you rented
in 2006 if used in computing your homestead credit.
If your landlord will not sign your rent certificate, check
the box on line 5. Complete lines 6 to 13, and attach copies
of each canceled check or money order receipt you have to
verify your rent. If you do not have verification of your rent,
contact the Department of Revenue at (608) 266-8641 for
additional instructions.
After you receive the completed rent certificate from your
landlord, fill in the allowable amounts from lines 10b and 13a
on lines 13, 14a, and 14c of Schedule 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 certificates 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
2006.
Instructions for Landlord/Authorized Representative
Fill in a separate rent certificate 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 certificate to the renter. Note: You may not
charge a fee for filling in a rent certificate.
Line 9b If you checked “No” on line 9a, do not complete the
rent certificate 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 2006, for the time this renter occupied it in 2006. Include
in the monthly rate any separate amounts the renter paid to
you for items such as a garage, parking space, utilities, ap-
pliances, 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). If the monthly rent for this unit changed in 2006, use
the extra columns to fill in each monthly rate separately.
Line 11b Fill in the number of months (or partial months)
you rented the unit to this renter in 2006. If you filled in more
than one amount on line 11a, fill in the number of months or
partial months each rate applied. For partial months, fill 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 2006
(generally, multiply line 11a by 11b).
Rent Certificate 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, 2006.
Line 11e Fill in this renter’s share of the total 2006 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, fill in 0.
Signature Review the rent certificate 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 certificate to the renter.
Signature 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 reflects 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 filled in $300
as your share on line 12.
a Rent collected per
month for this rental
unit for 2006. $ $ $ $
b Number of months this
rental unit was rented
to this renter in 2006.
c Total rent collected for this
rental unit for 2006. $
300 325
75
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-
-0-
$6,000
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:
Your allowable rent for occupancy only is $3,300, computed as
follows:
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
$4,800
$6,000
75
$3,600
$ 300
$3,300
$8,000
