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                                                                        FINAL DRAFT - 10/2/23
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    5                                                                                                                                                                                                                                 5
    6                                                                                                                                                                                               *235231*                          6
    7  2023 CRP, Certificate of Rent Paid                                                                                                                                                                                             7
    8                                                                                                                                                                                                                                 8
    9  Renter/Unit Information                                                                                                                                                                                                        9
    10                                                                                                                                                                                                                                10
    11 RENTER NAMEXXXXXXXXXXXXRENTER LAST NAMEXXXXXXXXXXXX 1234567891                                                                                                                                                                 11
    12 Renter First Name and Initial                     Renter Last Name                                                                                Electronic Certificate Number (ECN)                                          12
    13 UNIT ADDRESSXXXXXXXXXXXXXXXXXXXXXX  UNITXXXXXXXXXX  11/22/3333TO11/22/3333                                                                                                                                                     13
    14 Rental Unit Address                                                                        Unit                                                   Rented from (MM/DD/YYYY) to (MM/DD/YYYY)                                     14
    15 CITYXXXXXXXXXXXX   MN  1234567810                                                          COUNTYXXXXXXXX                                                                                    12          1000 15
    16 City                                     State    ZIP Code                                   County                                               Total Months Rented                              Total Adults Living in Unit 16
        
    17                                                                                                                                                                                                                                17
    18 Property Information                                                                                                                                                                                                           18
    19 Place an X if the property is:                                                                                                                                                                                                 19
    20                                                                                                                                                                                                                                20
    21 X  (1) Adult Foster Care       X    (2) Assisted Living      X      (3) Intermediate Care Facility                                                    1233333123123123123123 21
    22                                                                                                                                                   Property ID or Parcel Number                                                 22
    23  X  (4) Nursing Home           X    (5) Mobile Home          X      (6) Mobile Home Lot                                                                                                                999999999               23
    24                                                                                                                                                   Number of Units on This Property                                             24
    25                                                                                                                                                                                                                                25
    26 Rent Details                                                                                                                                                                                                                   26
    27 A. Was any rent paid by Medical Assistance (see instructions)?                                        X       (A) Yes     X No         If yes, enter amount: A                                         12345678                27
    28                                                                                                                                                                                                                                28
    29 B. Did the renter receive Minnesota Housing Support (formerly GRH)(see instructions)? X                       (B) Yes     X  No        If yes, enter amount: B                                         12345678 29
    30                                                                                                                                                                                                                                30
    31 Total Rent                                                                                                                                                                                                                     31
    32 1  Renter’s share of rent paid (see instructions) . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . . 1. . . .  .                     12345678                32
    33                                                                                                                                                                                                                                33
    34 2  Caretaker rent reduction (see instructions)  . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  .  2                    12345678 34
    35                                                                                                                                                                                                                                35
    36 3 Total rent (Add lines 1 and 2)  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . .  . 3         12345678 36
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    39 Property Owner                                                                                                                                                                                                                 39
    40                                                                                                                                                                                                                                40
    41 PROPERTY OWNERS NAMEXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX1112223333                                                                                                                                                                 41
    42 Property Owner Name                                                                                                                               Daytime Phone                                                                42
    43 OWNER ADDRESSXXXXXXXXXXXXXXXXXXXXXX CITYXXXXXXXXXXX MN   ZIPXXXXX                                                                                                                                                              43
    44 Property Owner Address                                                                       City                                                 State            ZIP Code                                                    44
    45                                                                                                                                                                                                                                45
    46 Sign Here                                                                                                                                                                                                                      46
    47 I declare that this certificate is correct and complete to the best of my knowledge and belief.                                                                                                                                47
    48                                                                                                                                                                                                                                48
    49                                                                                                                                                   11/22/3333                                                                   49
       Owner or Agent Signature                                                                                                                          Date (MM/DD/YYYY) 
    50                                                                                                                                                                                                                                50
    51 MANAGING AGENT NAMEXXXXXXXXXXXXXXXXXXXX                                                                                                           1234567891                                                                   51
    52 Managing Agent Name, If Applicable (please print)                                                                                                 Daytime Phone                                                                52
    53                                                                                                                                                                                                                                53
    54 Renter Instructions                                                                                                                                                                                                            54
    55 Use this certificate to complete Form M1PR, Homestead Credit Refund (for Homeowners) and Renter’s Property Tax Refund. When you file Form M1PR, you                                                                            55
    56 must attach all CRPs used to determine your refund. Keep copies of Form M1PR and all CRPs for your records.                                                                                                                    56
    57                                                                                                                                                                                                                                57
    58 Note: The property owner or managing agent must give each renter living in a unit a separate CRP showing that they paid an equal portion of the rent,                                                                          58
    59 regardless of the portion actually paid.                                                                                                                                                                                       59
    60                                                                                                                                                                                                                                60
    61 For forms and tax-related information, go to our website at www.revenue.state.mn.us, or call 651-296-3781 or 1-800-652-9094.                                                                                                   61
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    63                                                                                            9995                                                                                                                                63
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