Mo Ptc Form PDF Details

The Missouri Property Tax Credit Claim, commonly referred to as Form MO-PTC, stands as a vital financial tool for eligible Missourians, offering a mechanism to seek relief from property taxes or rent they have paid within the year. Now, envision a document designed with the utmost attention to details, requiring submissions in black ink without any staples, indicating its preparation must be meticulous. A pivotal aspect of this form is accommodating various groups, including those 65 and older, 100% disabled veterans, individuals with 100% disability, and surviving spouses aged 60 or above, each with distinct qualifications needing specific supporting documents like the SSA-1099 or letters from the Department of Veterans Affairs. The form demands a declaration of income from multiple sources, encompassing social security benefits, wages, pensions, and even public assistance, ensuring a comprehensive account of one’s financial intake. Critical too is the distinction in filing status, which affects the calculation of the credit - whether filing singly or combined as a married couple, with implications for total household income. The process is rigorous, emphasizing the necessity of attaching proof of rent paid and amount of property tax paid, conditional on the nature of your residence. Navigating through the MO-PTC form demonstrates an intersection of tax regulation and personal financial assessment, all aimed at providing fiscal relief to those who meet the stringent criteria, ultimately reflecting Missouri’s commitment to supporting its residents through tangible tax credit measures.

QuestionAnswer
Form NameMo Ptc Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesmissouri property tax credit, moptc form, missouri ptc tax, missouri ptc

Form Preview Example

Form

 

MO-PTC

2020 Property Tax Credit Claim

Print in BLACK ink only and DO NOT STAPLE.

For Privacy Notice, see Instructions.

Select Here for Amended Claim

Vendor Code

 

Department Use Only

 

 

 

Name

Social Security Number

-

Birthdate (MM/DD/YYYY)

First Name

-

0 0 1

 

 

 

 

Deceased

 

 

 

 

Deceased

 

 

 

 

in 2020 Spouse’s Social Security Number

 

 

 

 

in 2020

 

 

 

 

 

 

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s Birthdate (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M.I.

Last Name

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

Spouse’s First Name

 

M.I.

 

Spouse’s Last Name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In Care Of Name (Attorney, Executor, Personal Representative, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Present Address (Include Apartment Number or Rural Route)

City, Town, or Post Office

State

ZIP Code

_

County of Residence

Qualifications

Select only one qualification. Copies of letters, forms, etc., must be included with claim.

A. 65 years of age or older - You must be a full year resident. (Attach Form SSA-1099.)

B. 100% Disabled Veteran as a result of military service (Attach letter from Department of Veterans Affairs - see instructions.) C. 100% Disabled (Attach letter from Social Security Administration or Form SSA-1099.)

D. 60 years of age or older and received surviving spouse benefits (Attach Form SSA-1099.)

Filing Status

Select only one filing status. If married filing combined, you must report both incomes.

 

 

Single

Married - Filing Combined

Married - Living Separate for Entire Year

*20344010001*

20344010001

MO-PTC Page 1

Failure to provide the following attachments will result in denial or delay of your claim:

Verification of Rent Paid (Form 5674), Form(s) 1099, W-2, etc.

1.Enter the amount of social security benefits received by you, your spouse, and your minor children before any deductions and the amount of social security equivalent railroad retirement

 

 

benefits. Attach Form(s) SSA-1099 or RRB-1099 (TIER I)

1

 

 

2.

Enter the total amount of wages, pensions, annuities, dividends, interest income, rental income,

 

 

 

2

 

 

 

or other income. Attach Form(s) W-2, 1099, 1099-R, 1099-DIV, 1099-INT, 1099-MISC, etc. . . .

 

 

3.

Enter the amount of railroad retirement benefits (not included in Line 1) before any deductions.

 

 

 

3

 

 

 

Attach Form RRB-1099-R (TIER II)

 

 

4.

Enter the amount of veteran’s payments or benefits before any deductions.

 

 

 

4

 

 

 

Attach letter from Veterans Affairs (see instructions on page 5)

 

 

5.

Enter the total amount received by you, your spouse, and your minor children from: public

 

 

 

 

assistance, SSI, child support, or Temporary Assistance payments (TA and TANF). Attach a

 

 

Income

 

letter from the Social Security Administration that includes the amount of assistance received

 

 

 

5

 

 

and Form 1099 from Employment Security, if applicable

 

Household

 

 

 

 

6.

Total household income - Add Lines 1 through 5 and enter the total here

6

 

 

 

 

 

 

 

7.

Enter the appropriate amount from the options below

7

 

Single or Married Living Separate - Enter $0

Married and Filing Combined - rented or did not own your home for the entire year - Enter $2,000

Married and Filing Combined - owned and occupied your home for the entire year - Enter $4,000

 

8. Net household income - Subtract Line 7 from Line 6 and enter the amount here

8

 

• If you rented or did not own and occupy your home for the entire year and Line 8 is

 

 

greater than $27,200, you are not eligible to file this claim.

 

 

• If you owned and occupied your home for the entire year and Line 8 is greater

 

 

than $30,000, you are not eligible to file this claim.

 

Paid

 

 

 

9. If you owned your home, enter the total amount of property tax paid for your home, less special

 

 

assessments, or $1,100, whichever is less. Attach a copy of your 2020 paid real estate tax

 

Rent

 

 

 

receipt(s). If your home is on more than five acres or you own a mobile home, attach the

 

 

Assessor’s Certification (Form 948)

9

and

 

 

Tax

 

 

 

10. If you rented, enter the total amount from Certification of Rent Paid (Form MO-CRP) Line 9 or

 

 

$750, whichever is less. Attach a completed Verification of Rent Paid (Form 5674). NOTE: If you

 

RealEstate

11. Enter the total of Lines 9 and 10, or $1,100, whichever is less

11

 

rent from a facility that does not pay property tax, you are not eligible for a Property Tax Credit . .

10

*20344020001*

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.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

20344020001

MO-PTC Page 2

Credit

12. Apply amounts from Lines 8 and 11 to chart on pages 17-19 to figure your Property Tax Credit. You must use the chart on pages 17-19 to see how much refund you are allowed. . . . . . . . . . . . .

Reserved

12

.

00

Signature

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. By signing or entering my name in the “Signature” field(s) below, I am providing the Department of Revenue with my signature as required under Section 143.561, RSMo. Declaration of preparer (other than taxpayer) is based on all information of which he or she has any knowledge. As provided in Chapter 143, RSMo, a penalty of up to $500 shall be imposed on any individual who files a frivolous return. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit, or abatement if I employ such aliens.

Signature

 

Date (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s Signature (If filing combined, BOTH must sign)

 

Date (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

Daytime Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preparer’s Signature

 

Date (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preparer’s FEIN, SSN, or PTIN

 

Preparer’s Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preparer’s Address

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I authorize the Director of Revenue or delegate to discuss my claim and attachments with the preparer

or any member of his or her firm, or if internally prepared, any member of the internal staff . . . . . . . . . . . .

Did you pay a tax return preparer to complete your return, but the preparer failed or was unwilling to sign the return or provide an Internal Revenue Service preparer tax identification number? If you marked yes, please insert the preparer’s name, address, and phone number in the applicable sections of the signature block above.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Yes

No

No

A

K

R

Department Use Only

U

Form MO-PTC (Revised 12-2020)

Mail to: Taxation Division

Phone: (573) 751-3505

P.O. Box 2800

TTY: (800) 735-2966

Jefferson City, MO 65105-2800

Fax: (573) 522-1762

 

E-mail: PropertyTaxCredit@dor.mo.gov

*20344030001*

20344030001

MO-PTC Page 3

Form

 

MO-CRP

2020 Certification of Rent Paid

1. Social Security Number

 

-

-

One Form MO-CRP must be provided for each rental location in which you resided.

Failure to provide landlord information will result in denial or delay of your claim.

Spouse’s Social Security Number

 

-

 

-

 

 

 

 

Select this box if related to your landlord. If so, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Name (First, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address of Rental Unit (P.O. Box Not Allowed)

 

 

 

 

 

 

Apartment Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Landlord’s Name (First, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Landlord’s Street Address (Must be completed)

 

 

 

 

 

 

Apartment Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

4.Landlord’s Phone Number (Must be completed) From:

5. Rental Period During Year (MM/DD/YY)

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

(MM/DD/YY)

6. Enter your gross rent paid. Attach a completed Verification of Rent Paid (Form 5674). If you received housing assistance, enter the amount of rent you paid. Note: If you rent from a facility that does not pay property tax, you are not eligible for a Property Tax Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Select the appropriate box below and enter the corresponding percentage on Line 7 . . . . . . . . . . . . . . . . . . . . . . . .

6

7

.00

%

A.Apartment, House, Mobile Home, or Duplex - 100%

B.Mobile Home Lot - 100%

C.Boarding Home or Residential Care - 50%

D.Skilled or Intermediate Care Nursing Home - 45%

E.Hotel - 100%; if meals are included - 50%

F.Low Income Housing - 100% (Rent cannot exceed 40% of total household income.)

G.Shared Residence – If you shared your rent with relatives or friends (other than your spouse or children under 18), select the appropriate box based on the additional person(s) sharing rent:

1 (50%)

 

2 (33%)

 

3 (25%)

8. Net rent paid - Multiply Line 6 by the percentage on Line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Multiply Line 8 by 20%. Enter amount here and on Line 10 of Form MO-PTC or Line 12 of Form MO-PTS . . . . . . .

8

9

.

.

00

00

For Privacy Notice, see instructions.

Taxation Division

Attach to Form MO-PTC or MO-PTS and mail to the Missouri Department of Revenue.

Form MO-CRP (Revised 12-2020)

*20315010001*

20315010001

Form

 

MO-CRP

2020 Certification of Rent Paid

1. Social Security Number

 

-

-

One Form MO-CRP must be provided for each rental location in which you resided.

Failure to provide landlord information will result in denial or delay of your claim.

Spouse’s Social Security Number

 

-

 

-

 

 

 

 

Select this box if related to your landlord. If so, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Name (First, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address of Rental Unit (P.O. Box Not Allowed)

 

 

 

 

 

 

Apartment Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Landlord’s Name (First, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Landlord’s Street Address (Must be completed)

 

 

 

 

 

 

Apartment Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

4.Landlord’s Phone Number (Must be completed) From:

5. Rental Period During Year (MM/DD/YY)

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

(MM/DD/YY)

6. Enter your gross rent paid. Attach a completed Verification of Rent Paid (Form 5674). If you received housing assistance, enter the amount of rent you paid. Note: If you rent from a facility that does not pay property tax, you are not eligible for a Property Tax Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Select the appropriate box below and enter the corresponding percentage on Line 7 . . . . . . . . . . . . . . . . . . . . . . . .

6

7

.00

%

A.Apartment, House, Mobile Home, or Duplex - 100%

B.Mobile Home Lot - 100%

C.Boarding Home or Residential Care - 50%

D.Skilled or Intermediate Care Nursing Home - 45%

E.Hotel - 100%; if meals are included - 50%

F.Low Income Housing - 100% (Rent cannot exceed 40% of total household income.)

G.Shared Residence – If you shared your rent with relatives or friends (other than your spouse or children under 18), select the appropriate box based on the additional person(s) sharing rent:

1 (50%)

 

2 (33%)

 

3 (25%)

8. Net rent paid - Multiply Line 6 by the percentage on Line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Multiply Line 8 by 20%. Enter amount here and on Line 10 of Form MO-PTC or Line 12 of Form MO-PTS . . . . . . .

8

9

.

.

00

00

For Privacy Notice, see instructions.

Taxation Division

Attach to Form MO-PTC or MO-PTS and mail to the Missouri Department of Revenue.

Form MO-CRP (Revised 12-2020)

*20315010001*

20315010001

Form

 

MO-CRP

2020 Certification of Rent Paid

1. Social Security Number

 

-

-

One Form MO-CRP must be provided for each rental location in which you resided.

Failure to provide landlord information will result in denial or delay of your claim.

Spouse’s Social Security Number

 

-

 

-

 

 

 

 

Select this box if related to your landlord. If so, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Name (First, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address of Rental Unit (P.O. Box Not Allowed)

 

 

 

 

 

 

Apartment Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Landlord’s Name (First, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Landlord’s Street Address (Must be completed)

 

 

 

 

 

 

Apartment Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

4.Landlord’s Phone Number (Must be completed) From:

5. Rental Period During Year (MM/DD/YY)

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

(MM/DD/YY)

6. Enter your gross rent paid. Attach a completed Verification of Rent Paid (Form 5674). If you received housing assistance, enter the amount of rent you paid. Note: If you rent from a facility that does not pay property tax, you are not eligible for a Property Tax Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Select the appropriate box below and enter the corresponding percentage on Line 7 . . . . . . . . . . . . . . . . . . . . . . . .

6

7

.00

%

A.Apartment, House, Mobile Home, or Duplex - 100%

B.Mobile Home Lot - 100%

C.Boarding Home or Residential Care - 50%

D.Skilled or Intermediate Care Nursing Home - 45%

E.Hotel - 100%; if meals are included - 50%

F.Low Income Housing - 100% (Rent cannot exceed 40% of total household income.)

G.Shared Residence – If you shared your rent with relatives or friends (other than your spouse or children under 18), select the appropriate box based on the additional person(s) sharing rent:

1 (50%)

 

2 (33%)

 

3 (25%)

8. Net rent paid - Multiply Line 6 by the percentage on Line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Multiply Line 8 by 20%. Enter amount here and on Line 10 of Form MO-PTC or Line 12 of Form MO-PTS . . . . . . .

8

9

.

.

00

00

For Privacy Notice, see instructions.

Taxation Division

Attach to Form MO-PTC or MO-PTS and mail to the Missouri Department of Revenue.

Form MO-CRP (Revised 12-2020)

*20315010001*

20315010001

Department Use Only

Form

(MM/DD/YY)

 

 

5674 Verification of Rent Paid

 

 

 

 

Tenant and Rental Information

Landlord must complete this form each year.

Tax Year

Tenant’s Name

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Begin Date (MM/DD/YYYY)

Rental End Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Rent Paid for the Year

.

. .

. . . . .

. . . . .

.

. . . .

.

. . . . .

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. . .

 

 

 

 

 

 

 

 

 

00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

Amount of utilities included in monthly payment (if any).

. . . .

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00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did the tenant receive any housing assistance?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

. . . .

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. . . . . . . . . . . . . . . . . . . .If yes, how much rent was the tenant responsible for?

 

.

 

00

Did anyone reside at this dwelling with the above tenant?

 

 

 

 

 

 

 

 

No

 

 

 

If yes, how many were over the age of 18?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. . .

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Landlord Information

Landlord’s Name

Landlord’s Address

City

Telephone Number (Home)

Telephone Number (Work)

State

 

ZIP Code

 

 

 

 

 

 

Telephone Number (Cell)

Landlord’s Signature

Notice

Any person intentionally filing a fraudulent Property Tax Credit Claim may be prosecuted.

Section 143.941, RSMo. states in part: (...upon conviction thereof, be fined not more than ten thousand dollars, or be imprisoned in the county jail for not more than one year or by not less than two nor more than five years in the state penitentiary or by both fine and imprisonment together with the cost of prosecution.)

Form 5674 (Revised 12-2020)

Taxation Division

Phone: (573) 751-3505

Visit https://dor.mo.gov/

P.O. Box 2200

TTY: (800) 735-2966

for additional information.

Jefferson City, MO 65105-2200

Fax: (573) 522-1762

 

 

E-mail: propertytaxcredit@dor.mo.gov

 

Department Use Only

Form

(MM/DD/YY)

 

 

5674 Verification of Rent Paid

 

 

 

 

Tenant and Rental Information

Landlord must complete this form each year.

Tax Year

Tenant’s Name

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Begin Date (MM/DD/YYYY)

Rental End Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Rent Paid for the Year

.

. .

. . . . .

. . . . .

.

. . . .

.

. . . . .

. . . . .

. . .

 

 

 

 

 

 

 

 

 

00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

Amount of utilities included in monthly payment (if any).

. . . .

. . . .

.

. .

. . . . .

. . . . .

.

. . . .

.

. . . . .

. . . . .

. . .

 

 

 

 

 

 

 

 

 

00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did the tenant receive any housing assistance?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

. . . .

.

. .

. . . . .

. . . . .

.

. . . .

.

. . . . .

. . . . .

. . .

. .

. . . . . . . . .

. .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. . . . . . . . . . . . . . . . . . . .If yes, how much rent was the tenant responsible for?

 

.

 

00

Did anyone reside at this dwelling with the above tenant?

 

 

 

 

 

 

 

 

No

 

 

 

If yes, how many were over the age of 18?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. . .

. .

. .

. . . . .

. . . .

. .

. . .

. .

. . . . .

. . . . .

. . .

.

. . . . . . . . .

. .

.

 

 

 

 

 

 

 

Landlord Information

Landlord’s Name

Landlord’s Address

City

Telephone Number (Home)

Telephone Number (Work)

State

 

ZIP Code

 

 

 

 

 

 

Telephone Number (Cell)

Landlord’s Signature

Notice

Any person intentionally filing a fraudulent Property Tax Credit Claim may be prosecuted.

Section 143.941, RSMo. states in part: (...upon conviction thereof, be fined not more than ten thousand dollars, or be imprisoned in the county jail for not more than one year or by not less than two nor more than five years in the state penitentiary or by both fine and imprisonment together with the cost of prosecution.)

Form 5674 (Revised 12-2020)

Taxation Division

Phone: (573) 751-3505

Visit https://dor.mo.gov/

P.O. Box 2200

TTY: (800) 735-2966

for additional information.

Jefferson City, MO 65105-2200

Fax: (573) 522-1762

 

 

E-mail: propertytaxcredit@dor.mo.gov

 

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