2022 Iowa Mobile/Manufactured/Modular Home Owner 
                                                          Application for Reduced Tax Rate 
                                 Iowa Code section 435.22 and Iowa Administrative Code chapter 701 – 74  

Complete the following personal information: 
Your name:  _____________________________               Spouse name: ______________________________  
Your Social Security Number: _______________            Spouse Social Security Number: ________________  
Your birth date (MM/DD/YYYY):  _____________            Spouse birth date (MM/DD/YYYY): ______________  
Street address: ____________________________            City: ______________________________________  
State: ________________ ZIP: _______________            Telephone: _________________________________  

Were you age 23 or older as of December 31, 2021?  ................................................................ Yes ☐ No ☐ 
If “No,” stop. No credit is allowed. 
 
2021 Total household income for the entire year (For you and your                                                       
spouse). Read instructions before completing. 
                                                                           Use whole dollars only 
1. Wages, salaries, unemployment compensation, tips, etc. ..................................                             ,    .00 
                                                                            
2. In-kind assistance for housing expenses ............................................................                  ,    .00 
                                                                                                        
3. Title 19 benefits (excluding medical benefits) .....................................................                  ,    .00 
                                                                                                        
4. Social Security income .......................................................................................        ,    .00 
                                                                                                        
5. Disability income ................................................................................................    ,    .00 
                                                                                                        
6. All pensions and annuities ..................................................................................         ,    .00 
                                                                                                        
7. Interest and dividend income .............................................................................            ,    .00 
                                                                                                        
8. Profits from businesses and/or farming and capital gain ....................................                          ,    .00 
   If less than zero, enter 0.                                                                          

9. Money received from others living with you ........................................................                   ,    .00 
                                                                                                        
10. Other income ....................................................................................................    ,    .00 
                                                                                                        
11. Total household income. Add amounts from lines 1-10 ....................................                             ,    .00 
   (If $24,354 or greater, stop. No credit is allowed.)                                                 

I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this claim, and, 
to the best of my knowledge and belief, it is true, correct, and complete. 

Your signature: _________________________________________  Date: __________________________  

This claim must be filed or mailed to your county treasurer on or before June 1, 2022. The treasurer may 
extend the filing deadline to September 30, 2022. The Director of Revenue may extend the filing deadline 
through December 31, 2022.                               

                                                                                                                            54-014a (07/22/21) 

     2022 Iowa Mobile/Manufactured/Modular Home Owner Application for Reduced Tax Rate, page 2 

                                                   Instructions 
Who is Eligible?                                       taxable dividends and distributions received. 
• Total  2021  household income  was less  than        Include cash dividends and dividends paid in the 
 $24,354 and                                           form of merchandise or other property and report at 
• Age 23 or older as of December 31, 2021.             fair market value. 
Household income includes your income and your         Line 8:      Profit from business and/or  farming and 
spouse’s income, if living together, and monetary      capital gain  - Enter profit from business  and/or 
contributions received from other persons living       farming, and any gain received from the  sale or 
with  you. If  you  and  your  spouse are not living   exchange  of capital  assets. Capital losses are 
together, file separate claims.                        limited to the same amount that you are allowed to 
                                                       report for income tax purposes. Any loss must be 
Line    1:  Wages,       salaries,   unemployment
                                                       offset against gain, and a net loss must be reported 
compensation, tips, etc.  - Enter  the total wages, 
                                                       as zero. 
salaries,   unemployment       compensation,    tips,
bonuses, and commissions received. If you are          Line 9: Money received from others living with you 
living with your spouse, include the total amounts     - Enter money received from others living with you. 
received by both you and your spouse.                  Do not include goods and services received. 
Line 2: In-kind assistance  - Enter any portion of     Line 10:      Other income  - Enter total income 
your housing expenses, including utilities, that were  received from the following sources: 
paid for  you. Do not enter Federal Energy             • Child support and alimony payments. 
Assistance.                                            • Welfare  payments. Report       Family Investment 
Line 3:   Title 19 benefits  - Enter your Title 19       Program (FIP), children’s   Supplemental Security 
benefits received for housing  expenses. Do not          Income (SSI), and all other welfare program cash 
include medical benefits.                                payments. Do not include foster grandparents’ 
Line 4: Social  Security income   - Enter the total      stipends or non-cash government assistance 
Social Security benefits received, even if not           (food, clothing, food stamps,  medical supplies, 
reportable for income tax purposes. Include any          etc.). 
Medicare premiums withheld.                            • Insurance income not reported elsewhere. 
                                                       • Gambling and all other income not reported 
Line 5: Disability income   - Enter the total received 
                                                         elsewhere. 
for disability or injury compensation, even if not 
reportable for income tax purposes.                    Additional Information: 
                                                       The location of your county treasurer can be found 
Line 6: All pensions and annuities – Enter the total 
                                                       at       the  Iowa  County    Treasurers    website: 
received from pensions and annuities.  Include 
                                                       iowatreasurers.org .
retirement pay for military service,  even if not 
reportable for income tax purposes.                    For information about your Social Security benefits, 
                                                       go to the  Social Security Administration website 
Line 7:   Interest and  dividend income  - Enter       ssa.gov/myaccount. 
taxable interest income, plus  all interest income 
from federal, state, and municipal securities. Enter    

                                    For use by County Treasurer only 

                                Reduced            Square footage: __________________________________  
            Income               tax rate          Year of manufacture: ______________________________  
       $0.00 – 12,545.99             .00           * If year of manufacture is 2012-2015, apply 90% factor. 
 12,546.00 – 14,021.99               .03 
                                                   * If year of manufacture is 2011 or before, apply 80% factor. 
 14,022.00 – 15,497.99               .06 
                                                   Regular tax: _____________________________________  
 15,498.00 – 18,449.99               .10 
 18,450.00 – 21,401.99               .13           Reduced tax:  ____________________________________  
 21,402.00 – 24,353.99               .15           Reimbursement: __________________________________  

                                                                                            54-014b (07/22/21)