Wisconsin Homestead Credit Rent Certificate

Homestead Credit Rent Certificate
2020 I-017 Rent Certificate (fillable)
CAUTION:
 Schedule H or H-EZ must be
completed and filed with this rent
certificate

Instructions

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2020

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	

Time you actually lived at this address in 2020 	 From	

M.I.

Social security number

State	

M

M

D

D

2020	

To	

M

Zip

M

D

D

2020

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 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  	 3c

.00

4	a	 Total rent collected for this rental unit for 2020 – 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 2020, enter monthly rent paid . . . . . . . . .  	 4b

.00

	 c	 If monthly rent changed during 2020, 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	a	 Number of occupants in this rental unit – do NOT count spouse or children under 18 . . . . . . . . . . . . . . . . 	 5a
	b	Renters, if line 5a is more than 1, did each occupant pay an equal share of living
		 expenses? (if no, complete shared living expenses schedule on page 2) 	5b	

Yes	

No

6		 This renter’s share of total 2020 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. 07-20)

Date	

Print name (must match signature)

Renter’s
2020 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 5b on page one is “No.”
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, complete line 5b if applicable,
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 5b on page 1 is “No.” 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 2020. 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 5a  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, 2020.
Line 5b Do not complete this line. This will be completed by the
renter.
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.

Applicable Laws and Rules
This document provides statements for interpretations of the following provisions of Wisconsin Statutes in effect as of July 7, 2020:
Chapter 71, Wis. Stats.
Laws enacted and in effect after July 7, 2020, new administrative rules, and court decisions may change the interpretations in this
document. Guidance issued prior to July 7, 2020, that is contrary to the information in this document is superseded by this document,
pursuant to sec. 73.16(2)(a), Wis Stats.

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