CAUTION: Schedule H or H-EZ must be completed and filed with this rent certificate
| CAUTION: Schedule H or H-EZ must be completed and filed with this rent certificate |
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Rent Certificate
Wisconsin Department of Revenue 2023
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 M.I. Social security number
Address of rental property (property must be in Wisconsin) City State Zip
Time you actually lived at this address in 2023 From 2023 To 2023
M M D D M M D D
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? 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 certificate for rent of a mobile/manufactured: Home? a 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 2023 ........................................ 3c .00
4 a Total rent collected for this rental unit for 2023 - do NOT include amounts received directly from a gov-
ernmental agency, Wisconsin rental assistance program payments, security deposits, or late fees 4a .00
b If monthly rent paid didn’t change during 2023, enter monthly rent paid ......... 4b .00
c If monthly rent changed during 2023, 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 2023 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 Date Print name (must match signature)
I-017i
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Renter’s Renter’s
2023 Rent Certificate name SSN Page 2of 2
Address of rental property
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:
1 Total rent paid (line 1a) .............. 1 .00
2 Shared living expenses
you paid (line 5b) ....... 2 .00
Step 2: List the total amount (not the monthly amount) of
all shared living expenses (rent, food, utilities, and other) 3 Total shared living
paid by all occupants and the amount that you paid: expenses (line 5a) ...... 3 .00
Shared Living Total Paid by Amount 4 Divide line 2 by line 3. Fill
Expenses All Occupants You Paid
in decimal amount .................. 4 .
Rent 1a) .00 1b) .00 5 Multiply line 1 by line 4 ............... 5 .00
Food 2a) .00 2b) .00 6 Value of food and services provided by
Utilities 3a) .00 3b) .00 landlord (line 7 of page 1) ............. 6 .00
Other 4a) .00 4b) .00 7 Subtract line 6 from line 5. This is your
allowable rent. Fill in here and on the
Total 5a) .00 5b) .00 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 Lines 2a and 2b If you checked “No” on line 2a, do not complete
the social security number. Then give to your landlord to the rent certificate unless line 2b applies.
complete and sign.
Line 4a Fill in the total rent collected from all occupants for
If your landlord won’t sign, place a checkmark in the designated this unit for the time occupied by this renter in 2023. Include
area. Complete the “Landlord or Authorized Representative” any separate amounts the renter paid to you for items such as
section, and attach a copy of each canceled check or bank parking, a garage, utilities, appliances, or furnishings. Do not
money order you have to verify your rent. Any portion not veri- include rent for a prior year, late fees, security deposit paid during
fied will not be allowed. the year, or amounts you received directly from a governmental
agency through a subsidy, voucher, grant, etc., or Wisconsin
Note: Do NOT sign the rent certificate yourself. Rent certifi- rental assistance program payments for the unit (except amounts
cates signed by you or someone other than the landlord or his/ an agency paid as a claimant’s representative payee).
her authorized representative will not be accepted.
Line 5a Fill in the number of adult occupants who lived in this
After your landlord returns the completed rent certificate, enter rental unit during the rental period. Do not count the renter’s
your social security number, complete line 5b if applicable, spouse or children under age 18 as of December 31, 2023.
and then fill in the allowable amounts from lines 3c and 8a (or
line 7 of the above Shared Living Expenses Schedule – see Line 5b Do not complete this line. This will be completed by the
instructions below) on Schedule H or H-EZ, as appropriate. renter.
Renter Instructions for Shared Living Expenses Line 7 Fill in this renter’s share of the value of food and personal
Schedule services (medical, laundry, transportation, counseling, grooming,
recreational, therapeutic, etc.) you provided for this rental unit.
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 Signature Review the rent certificate to be sure that all applicable
filled in, paid rent will be divided by the number of occupants. 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 or interpretations of the following laws and regulations enacted as of August 15, 2023: ch. 71,
Wis. Stats.
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