2021 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, 2020?  ................................................................ Yes ☐ No ☐ 
If “No,” stop. No credit is allowed. 
 
2020 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 $24,206 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, 2021. The treasurer may 
extend the filing deadline to September 30, 2021. The Director of Revenue may extend the filing deadline 
through December 31, 2021.                               

                                                                                                                            54-014a (10/20/2020) 

     2021 Iowa Mobile/Manufactured/Modular Home Owner Application for Reduced Tax Rate, page 2 

                                                   Instructions 
Who is Eligible?                                       taxable dividends and  distributions received. 
• Total  2020  household income was less  than         Include cash dividends and dividends paid in the 
 $24,206 and                                           form of merchandise or other property and report at 
• Age 23 or older as of December 31, 2020.             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 
                                                       For information about your Social Security benefits, 
reportable for income tax purposes. 
                                                       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 – 12,469.99             .00           * If year of manufacture is 2012-2015, apply 90% factor. 
 12,470.00 – 13,936.99               .03 
                                                   * If year of manufacture is 2011 or before, apply 80% factor. 
 13,937.00 – 15,403.99               .06 
                                                   Regular tax: _____________________________________  
 15,404.00 – 18,337.99               .10 
 18,338.00 – 21,271.99               .13           Reduced tax: ____________________________________  
 21,272.00 – 24,205.99               .15           Reimbursement: _________________________________  

                                                                                           54-014b (10/19/2020)