OFFICIAL USE ONLY
Notarize:
Subscribed and sworn before me this
day of 20
x x
OCCUPANCY AFFIDAVIT
I am, or am filing on behalf of, the claimant named above. I certify that I was unable to obtain the landlord’s signature on the PA Rent Certificate
for the following reason(s):
Affidavit: I certify that I am, or am filing on behalf of, the claimant named
above. I also affirm all the information on the above PA Rent Certificate
and Occupancy Affidavit is true, correct and complete to the best of my
knowledge, information and belief.
Claimant's Signature
Signature of Notary Public
Date
LANDLORD’S OATH: (Read carefully before signing)
I certify that the information provided on this PA Rent Certificate is true, correct and complete to the best of my knowledge, information and
belief. I further certify that – fill in the applicable oval(s).
I was required to pay 2019 property taxes on the property in which the claimant resided in 2019.
I made, or was required to make, a payment in lieu of taxes for 2019 on the property in which the claimant resided in 2019.
The property in which the claimant resided in 2019 was tax exempt.
Other names, excluding the spouse or minor children, appear on the lease.
X
Landlord’s Signature
Date
1. Street address of the residence for which the claimant paid rent 3. Rental unit is (fill in the appropriate oval):
City, State, ZIP Code
2. Owner’s business name or landlord’s name (last, first, middle initial) if an individual
Landlord’s Address
City, State, ZIP Code
Landlord’s EIN (if applicable) and daytime telephone number
( )
Name as shown on PA-1000 Social Security Number
You may make photocopies of this form as needed.
If filing as a renter, you must provide proof of the rent you paid. If you rented at more than one address, you must submit proof for each address.
PA RENT CERTIFICATE
Your landlord must provide all the information on Lines 1 through 8. Your landlord, or your landlord’s authorized agent, must sign this PA Rent
Certificate. If your landlord, or your landlord’s authorized agent, does not sign this PA Rent Certificate, you must complete Lines 1 through 8
and the Rental Occupancy Affidavit below. Your Rental Occupancy Affidavit must be notarized.
4. What was the amount of rent per month? (Include only the amount charged for rental.
Do not include security deposits or amounts paid for food, medicine, medical care
or personal care.) If your rental amounts changed during the year, please explain in the
space provided. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. How much of the monthly rental amount was paid or subsidized
by a governmental agency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.
6. Total monthly amount of rent paid. (Subtract Line 5 from Line 4.) . . . . . . . . . . . . . . 6.
7. Number of months unit was occupied by the claimant in 2019.
(If less than 12 months, please explain in the space provided.) . . . . . . . . . . . . . . . . . . 7.
8. What was the total rent paid in 2019 by the claimant?
(Multiply Line 6 by Line 7.) Enter the amount here and on Line 16 of the claim form
or the appropriate line(s) of Schedules D, E or F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.
YOU MUST COMPLETE ALL LINES. IF NONE, ENTER “0”.
Explanation of Item 4.
Explanation of Item 7.
Dollars Cents
Apartment in a House Mobile Home Lot
Apartment Building Nursing Home
Boarding Home Private Home
Mobile Home Assisted Living
Personal Care Home
Building Name:
Domiciliary Care
Foster Care
If Domiciliary or Foster Care or if a Boarding or Personal Care
Home, you must submit a copy of your contract agreement.
PA Rent Certificate
PA Rent Certificate and
Rental Occupancy Affidavit
2019
PA-1000 RC 04-19
PA Department of Revenue
(FI)
1905210058
1905210058
1905210058
Please sign and date after printing.
Claimant's Signature. Please sign after printing.
Signature of Notary Public. Please sign after printing.
