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FINAL DRAFT - 10/2/23
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6 *235231* 6
7 2023 CRP, Certificate of Rent Paid 7
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9 Renter/Unit Information 9
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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
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18 Property Information 18
19 Place an X if the property is: 19
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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
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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
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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
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31 Total Rent 31
32 1 Renter’s share of rent paid (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. . . . . 12345678 32
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34 2 Caretaker rent reduction (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 12345678 34
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36 3 Total rent (Add lines 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 12345678 36
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39 Property Owner 39
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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
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46 Sign Here 46
47 I declare that this certificate is correct and complete to the best of my knowledge and belief. 47
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49 11/22/3333 49
Owner or Agent Signature Date (MM/DD/YYYY)
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51 MANAGING AGENT NAMEXXXXXXXXXXXXXXXXXXXX 1234567891 51
52 Managing Agent Name, If Applicable (please print) Daytime Phone 52
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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
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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
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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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