Wisconsin Homestead Credit Rent Certificate

Homestead Credit Rent Certificate
2019 I-017 Rent Certificate
CAUTION:
 Schedule H or H-EZ must be
completed and filed with this rent
certificate
 A 2019 Schedule H or H-EZ may not
be filed prior to January 1, 2020

2019

Rent Certificate
Wisconsin Department of Revenue

NOTE:	 •	 Attach to Schedule H or H‑EZ
• Alterations (whiteouts, erasures, etc.) or errors void this
rent certificate.
• Only attach rent certificate if filing a homestead credit claim

Renter (Claimant) – Enter Social Security Number AFTER your landlord fills in section below and signs.
Legal last name

Legal first name	

Address of rental property (property must be in Wisconsin)	

City	

M.I.

Social security number

State	

Time you actually lived at this address in 2019 	 From	
M

M

D

D

2019	

Zip

To
M

M

D

D

2019

Do NOT sign your rent certificate.
If your landlord won’t sign, complete fields above and below and lines 1 to 8, attach rent verification (see instructions), and
check here.

Landlord or Authorized Representative
Name of property owner

Telephone number

(	)
Address	

City	

State	Zip

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? 	

Yes

No

3a

Yes

No

b Home site/Lot? 	 3b

Yes

No

2a	

	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 certificate for rent of a mobile/manufactured: 	 a Home? 	

c	 Mobile or manufactured home taxes or municipal permit fees
you collected from this renter for 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  	 3c

.00

4	a	 Total rent collected for this rental unit for 2019 – do NOT include amounts received
directly from a governmental agency, security deposits, or late fees . . . . . . . . . . . . . . . . .  	 4a

.00

b	 If monthly rent paid didn’t change during 2019, enter monthly rent paid . . . . . . . . .  	 4b

.00

c	 If monthly rent changed during 2019, enter rent paid for each month below. Do not include security deposits or late fees.
Jan.

.00

Feb.

.00

Mar.

.00

Apr.

.00

May

.00

June

.00

July

.00

Aug.

.00

Sept.

.00

Oct.

.00

Nov.

.00

Dec.

.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 2019 rent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  	 6

.00

7		 Value of food and services provided by landlord (this renter’s share) . . . . . . . . . . . . . . . .  	 7

.00

8	a	 Rent paid for occupancy only – Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . .  	 8a

.00

	b	 Was heat included in the rent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  	 8b 	

Yes 	

No

I certify that the information shown on this rent certificate is true, correct, and complete to the best of my knowledge.
Signature (by hand) of landlord or authorized representative	

I-017i (R. 5-19)

Date	

Print name (must match signature)

Renter’s
2019 Rent Certificate name

Renter’s
SSN

Address of rental property

Page  2 of 2

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.

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

Step 3: Using the amounts listed in Step 2, compute your allowable
rent paid for occupancy only:

.00

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

Total Paid by
All Occupants

Amount
You Paid

	Rent	 1a)

.00

1b)

.00

	Food	 2a)

.00

2b)

.00

	Utilities	 3a)

.00

3b)

.00

	Other	 4a)

.00

4b)

.00

	Total	 5a)

.00

5b)

.00

2	 Shared living expenses
	 you paid (line 5b). . . . . . . . 	2

.00

3	 Total shared living
	 expenses (line 5a) . . . . . . . 	3

.00

4	 Divide line 2 by line 3. Fill
	 in decimal amount . . . . . . . . . . . . . . . . . . . 	4

.

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

.00

6	 Value of food and services provided by
	 landlord (line 7 of page 1). . . . . . . . . . . . . . 	6

.00

7	 Subtract line 6 from line 5. This is your
	 allowable rent. Fill in here and on the
	 applicable rent line of Schedule H or
	 Schedule H-EZ . . . . . . . . . . . . . . . . . . . . . 	7

.00

Instructions for Renter (Claimant)

Instructions for Landlord/Authorized Representative

Complete all fields in the “Renter (Claimant)” section except
the social security number. Then give to your landlord to
complete and sign.

Lines 2a and 2b  If you checked “No” on line 2a, do not
complete the rent certificate unless line 2b applies.

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 verified will not be allowed.
Note: Do NOT sign the rent certificate yourself. Rent certificates signed by you or someone other than the landlord
or his/her authorized representative will not be accepted.
After your landlord returns the completed rent certificate,
enter your social security number and then fill in the
allowable amounts from lines 3c and 8a (or line 7 of the
above Shared Living Expenses Schedule – see instructions
below) on Schedule H or H‑EZ, as appropriate.

Renter Instructions for Shared Living Expenses
Schedule
Complete this schedule if line 5 of the rent certificate shows
2 or more and each occupant did not pay an equal share of
the living expenses. All lines on the schedule must be filled
in. If all lines on the schedule are not filled in, paid rent will
be divided by the number of occupants.

Line 4a  Fill in the total rent collected from all occupants for
this unit for the time occupied by this renter in 2019. 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, late fees, security deposit
paid during the 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 5  Fill in the number of adult occupants who lived in this
rental unit during the rental period. Do not count the renter’s
spouse or children under age 18 as of December 31, 2019.
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 certificate to be sure that all
applicable fields and lines have an entry. Sign (by hand) and
date, print your name, and return the rent certificate to the
renter. Only an original signature is acceptable.