2021 Iowa Special Assessment Property Tax Credit 
                            Iowa Code section 425.23(3) and Iowa Administrative Code rule 701—73.27 
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 65 or older, or totally disabled and age 18 or older, as of  

December 31, 2020?  .................................................................................................................. Yes ☐ No ☐ 

If “No,” stop. No credit is allowed. 
If you are under age 65 and totally disabled, you must include proof of disability, such as a current statement 
from Social Security or a letter from your doctor. 
                                                                                                                           
2020 Total household income for the entire year (For you and your 
                                                                                                                         Use whole dollars only 
spouse). Read instructions before completing.
                                                                                                                            
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.                                                               
   If less than zero, enter 0………………………………………………………. ..........                                                                ,                 .00 
                                                                                                                              
9. Money received from others living with you .........................................................                       ,                 .00 
                                                                                                                            
10. Other income ......................................................................................................       ,                 .00 
                                                                                                                            
11. Add amounts from lines 1 through 10 .................................................................                     ,                 .00 
                                                                                                                            
12. Medical and care expenses (Totally Disabled individuals only). .........................                                  ,                 .00 
                                                                                                                            
13. Total household income (Subtract line 12 from line 11) ......................................                             ,                 .00 
                                                                                                                            
   (If line 13 is more than $12,470 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 September 30, 2021. 

                                                                                                                              54-036a (10/20/2020) 

                                           2021 Iowa Special Assessment Property Tax Credit, page 2 

                                            Instructions 
Who is Eligible?                                         Line 8: Profit from business and/or farming and 
Total household income was not more than $12,470         capital gain  - Enter  profit from business  and/or 
and:                                                     farming, and any gain received from the  sale or 
•  Age 65 or older by December 31, 2020, or              exchange of capital assets. Capital losses are limited 
                                                         to the same amount that you are allowed to report for 
•  Totally disabled and age 18 or older by December 
                                                         income tax purposes. Any loss must be offset against 
 31, 2020. 
                                                         gain, and a net loss must be reported as zero. 
Household income includes  your income  and  your 
                                                         Line 9:  Money received from others  living with 
spouse’s income, if living together, and  monetary 
                                                         you - Enter money received from others living with 
contributions received from other persons living with 
                                                         you. Do not include goods and services received. 
you. If you and your spouse are not living together, 
each may file a separate claim.                          Line 10: Other income - Enter total income received 
                                                         from the following sources: 
Line 1:     Wages, salaries,        unemployment
                                                         •
compensation,  tips, etc.  -  Enter the  total wages,      Child support and alimony payments. 
                                                         •
salaries,  unemployment       compensation,       tips,    Welfare payments.  Include  Family Investment 
bonuses, and commissions received.                         Program (FIP), children’s Supplemental Security 
                                                           Income (SSI), and all other welfare program cash 
Line  2: In-kind assistance  - Enter any portion of 
                                                           payments.  Do not  include foster grandparents’ 
your housing expenses, including utilities, that were 
                                                           stipends or non-cash government assistance (ex: 
paid  for you. Do not  include  Federal Energy 
                                                           food, clothing,  food stamps, medical supplies, 
Assistance. 
                                                           etc.). 
Line 3: Title 19 benefits - Enter your Title 19 benefits • Insurance income not reported elsewhere. 
received for housing  expenses.  Do  not include         • Gambling, and  all other income,  not reported 
medical benefits.                                          elsewhere. 
Line 4: Social  Security income  -  Enter the total      Line 12: Medical  and care expenses  -    Enter all 
Social Security  benefits received, even if not          medical and  necessary care expenses  paid during 
reportable  for income tax purposes. Include any         the year which were related to your disability. These 
Medicare premiums withheld.                              are the same as you are allowed to deduct for federal 
Line 5: Disability income - Enter the total received     income tax. Do not enter an amount on line 12 unless 
for disability or injury compensation, even if not       you are totally disabled and incurred medical or care 
reportable for income tax purposes.                      expenses attributable to your disability. 
Line 6: All pensions and annuities - Enter the total     Line 13: Total household income - Subtract line 12 
received  from pensions  and annuities.  Include         from line  11. If more than $12,470  no credit is 
retirement pay for  military service,  even if not       allowed. 
reportable for income tax purposes.                      Additional Information: 
Line 7: Interest and dividend income  -     Enter        The location of your county treasurer can be found at 
taxable interest income, plus all interest income from   the Iowa Treasurers website:iowatreasurers.org. For 
federal, state, and municipal securities.                information about your Social Security benefits, go to 
Enter taxable dividends and distributions received.      the   Social Security   Administration    website: 
Include cash dividends and dividends paid in the form    ssa.gov/myaccount. 
of merchandise or other property.  Report at fair 
market value. 

                                   For use by County Treasurer only 
Installment number: _________________________ Annual special assessment payment: ______________  
State reimbursement: ________________________  
 
                                                                                           54-036b (10/16/2020)