CAUTION:
Schedule H or H-EZ must be
completed and filed with this rent
certificate
Rent Certificate
2023
Wisconsin Department of Revenue
I- 017i
NOTE: • Attach to Schedule H or H-EZ
• Alterations (whiteouts, erasures, etc.) or errors void this
rent certificate.
• Only attach rent certificate if filing a homestead credit claim
Do NOT sign your rent certificate.
If your landlord won’t sign, complete fields above and below and lines 1 to 8, attach rent verification
(see instructions), and
check here.
Time you actually lived at this address in 2023 From 2023 To 2023
M M D D M M D D
Landlord or Authorized Representative
Name of property owner
Address City State Zip
Telephone number
( )
5 a Number of occupants in this rental unit – do NOT count spouse or children under 18 ............... 5a
b
Renters, if line 5a is more than 1, did each occupant pay an equal share of living
expenses? (if no, complete shared living expenses schedule on page 2) 5b Yes No
6 This renter’s share of total 2023 rent ......................................... 6
7 Value of food and services provided by landlord (this renter’s share) ................ 7
8 a Rent paid for occupancy only – Subtract line 7 from line 6 ........................ 8a
b Was heat included in the rent? ................................ 8b Yes No
.00
.00
.00
Signature (by hand) of landlord or authorized representative Date Print name (must match signature)
I certify that the information shown on this rent certificate is true, correct, and complete to the best of my knowledge.
.00
.00
.00
Jan.
May
Sept.
.00
.00
.00
Feb.
June
Oct.
.00
.00
.00
Mar.
July
Nov.
.00
.00
.00
Apr.
Aug.
Dec.
Renter (Claimant) – Enter Social Security Number AFTER your landlord fills in section below and signs.
Legal last name
Address of rental property (property must be in Wisconsin) City State Zip
Social security numberLegal first name M.I.
1 Is the rental property a long-term care facility, CBRF, or nursing home? 1 Yes No
2 a Is the above rental property subject to property taxes? 2a Yes No
b If 2a is “No” and you are a sec. 66.1201 municipal housing authority
that makes payments in lieu of taxes, check here ................. 2b
3 Is this certificate for rent of a mobile/manufactured: a Home? 3a Yes No
b Home site/Lot? 3b Yes No
c Mobile or manufactured home taxes or municipal permit fees
you collected from this renter for 2023 ........................................ 3c
4 a Total rent collected for this rental unit for 2023 - do NOT include amounts received directly from a gov-
ernmental agency, Wisconsin rental assistance program payments, security deposits, or late fees 4a
b If monthly rent paid didn’t change during 2023, enter monthly rent paid ......... 4b
c If monthly rent changed during 2023, enter rent paid for each month below. Do not include security deposits or late fees.
.00
.00
.00
Save
Print
Clear
Tab to navigate within form. Use mouse to check
applicable boxes, press spacebar or press Enter.
Instructions
Applicable Laws and Rules
This document provides statements or interpretations of the following laws and regulations enacted as of August 15, 2023: ch. 71,
Wis. Stats.
2023
Rent Certificate
Page 2 of 2
Renter’s
name
Renter’s
SSN
Address of rental property
Shared Living Expenses Schedule
– To be completed by renter only if line 5b on page one is “No.”
Instructions for Renter (Claimant)
Complete all fields in the “Renter (Claimant)” section except
the social security number. Then give to your landlord to
complete and sign.
If your landlord won’t sign, place a checkmark in the designated
area. Complete the “Landlord or Authorized Representative”
section, and attach a copy of each canceled check or bank
money order you have to verify your rent. Any portion not veri-
fied will not be allowed.
Note: Do NOT sign the rent certificate yourself. Rent certifi-
cates signed by you or someone other than the landlord or his/
her authorized representative will not be accepted.
After your landlord returns the completed rent certificate, enter
your social security number, complete line 5b if applicable,
and then fill in the allowable amounts from lines 3c and 8a (or
line 7 of the above Shared Living Expenses Schedule – see
instructions below) on Schedule H or H-EZ, as appropriate.
Renter Instructions for Shared Living Expenses
Schedule
Complete this schedule if line 5b on page 1 is “No.” All lines on
the schedule must be filled in. If all lines on the schedule are not
filled in, paid rent will be divided by the number of occupants.
Instructions for Landlord/Authorized Representative
Lines 2a and 2b If you checked “No” on line 2a, do not complete
the rent certificate unless line 2b applies.
Line 4a Fill in the total rent collected from all occupants for
this unit for the time occupied by this renter in 2023. Include
any separate amounts the renter paid to you for items such as
parking, a garage, utilities, appliances, or furnishings. Do not
include rent for a prior year, late fees, security deposit paid during
the year, or amounts you received directly from a governmental
agency through a subsidy, voucher, grant, etc., or Wisconsin
rental assistance program payments for the unit (except amounts
an agency paid as a claimant’s representative payee).
Line 5a Fill in the number of adult occupants who lived in this
rental unit during the rental period. Do not count the renter’s
spouse or children under age 18 as of December 31, 2023.
Line 5b Do not complete this line. This will be completed by the
renter.
Line 7 Fill in this renter’s share of the value of food and personal
services (medical, laundry, transportation, counseling, grooming,
recreational, therapeutic, etc.) you provided for this rental unit.
Signature Review the rent certificate to be sure that all applicable
fields and lines have an entry. Sign (by hand) and date, print your
name, and return the rent certificate to the renter. Only an original
signature is acceptable.
1 Total rent paid (line 1a) .............. 1
2
Shared living expenses
you paid (line 5b) ....... 2
3
Total shared living
expenses (line 5a) ...... 3
4
Divide line 2 by line 3. Fill
in decimal amount .................. 4
5
Multiply line 1 by line 4 ............... 5
6
Value of food and services provided by
landlord (line 7 of page 1) ............. 6
7
Subtract line 6 from line 5. This is your
allowable rent. Fill in here and on the
applicable rent line of Schedule H or
Schedule H-EZ .................... 7
Step 3: Using the amounts listed in Step 2, compute your allowable
rent paid for occupancy only:
.00
.00
.00
.00
.00
.00
Step 1: List name(s) of other occupants:
Step 2: List the total amount (not the monthly amount) of
all shared living expenses (rent, food, utilities, and other)
paid by all occupants and the amount that you paid:
1b)
2b)
3b)
4b)
5b)
Shared Living
Expenses
Rent
1a)
Food
2a)
Utilities
3a)
Other
4a)
Total
5a)
Amount
You Paid
Total Paid by
All Occupants
.00 .00
.00
.00
.00
.00
.00
.00
.00
.00
.
Return to Form
