PA-1000
Property Tax or Rent
Rebate Claim 05-21
PA Department of Revenue
P.O. Box 280503
Harrisburg PA 17128-0503
OFFICIAL USE ONLY
Spouse’s Social Security NumberYour Social Security Number
Check your label for accuracy. If incorrect, do not use the label. Complete Section I.
Fill in only one oval in each
section.
I
III
II
If Spouse is
Deceased, fill
in the oval.
1. I am filing for a rebate as a:
P. Property Owner – See
instructions
R. Renter – See instructions
B. Owner/Renter – See
instructions
2. I Certify that as of Dec. 31, 2021,
I am (a):
A. Claimant age 65 or older
B. Claimant under age 65,
with a spouse age 65 or
older who resided in the
same household
C. Widow or widower, age
50 to 64
D. Permanently disabled
and age 18 to 64
3.
Filing on behalf of a
decedent
Dollars Cents
4.
5.
6.
8.
7.
9.
11a.
10.
11b.
13.
IMPORTANT: You must submit proof of the income you reported – See the instructions on Pages 7 to 9.
11c.
11d.
11e.
11f.
11g.
12.
2021
4. Social Security, SSI and SSP Income (Total benefits $ divided by 2) . . . . . . . . . .
5. Railroad Retirement Tier 1 Benefits (Total benefits $ divided by 2) . . . . . . . . . . .
8. Gain or Loss on the Sale or Exchange of Property. . . . . . . . . If a loss, fill in this oval. . . . .
7. Interest and Dividend Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11a. Salaries, wages, bonuses, commissions, and estate and trust income. . . . . . . . . . . . . . . . . . . . .
12. Claimants with Federal Civil Service Retirement System Benefits enter $9,514 or $19,028.
See the instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LOSS
9. Net Rental Income or Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . If a loss, fill in this oval. . . . .
10. Net Business Income or Loss . . . . . . . . . . . . . . . . . . . . . . . . . If a loss, fill in this oval. . . . .
LOSS
LOSS
11b. Gambling and Lottery winnings, including PA Lottery winnings, prize winnings and the value
of other prizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11c. Value of inheritances, alimony and spousal support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11d. Cash public assistance/relief. Unemployment compensation and workers’ compensation,
except Section 306(c) benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11e. Gross amount of loss of time insurance benefits and disability insurance benefits,
and life insurance benefits, except the first $5,000 of total death benefit payments. . . . . . . . . . . .
11f. Gifts of cash or property totaling more than $300, except gifts between
members of a household. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11g. Miscellaneous income and annualized income amount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Income.
13. TOTAL INCOME. Add only the positive income amounts from Lines 4 through 11g and subtract
the amount on Line 12. See Page 3 for income limitations. Enter this amount on Line 23. . . . . . . .
6. Total Benefits from Pension, Annuity, IRA Distributions and Railroad Retirement Tier 2 (Do not
include federal veterans’ disability payments or state veterans’ payments.) . . . . . . . . . . . . . . . . . . .
TOTAL INCOME received by you and your spouse during 2021
CODES
REQUIRED
*
**
(FI)
Claimant’s Birthdate Spouse’s Birthdate
Spouse’s First Name MI
PLEASE WRITE IN YOUR SOCIAL SECURITY NUMBER(S) ABOVE
Last Name First Name MI
First Line of Address
Second Line of Address
State ZIP CodeCity or Post Office
Daytime Telephone Number
2105010058
2105010058
School District CodeCounty Code
Country Code
START
MM/DD/YY
MM/DD/YY
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IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
Claim filing deadline – June 30, 2022
You can call 1-888-728-2937 after June 1 to verify the status of your claim.
14.
15.
16.
17.
19.
15. Property Tax Rebate. Enter the maximum standard rebate Compare this amount to line 14 and
amount from Table A for your income level here: (_______) enter the lesser amount to the right.
17. Multiply Line 16 by 20 percent (0.20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OWNER – RENTERONLY
19. Property Tax/Rent Rebate. Enter the maximum Compare this amount to the sum of
rebate amount from Table A for your income Lines 15 and 18 and enter the lesser
level here: (_______) amount to the right.
RENTERS ONLY
16. Total 2021 rent paid. Submit PA Rent Certificate and/or rent receipts . . . . . . . . . . . . . . . . . . . . . .
PROPERTY OWNERS ONLY
14. Total 2021 property tax. Submit copies of receipted tax bills. . . . . . . . . . . . . . . . . . . . . . . . . . . .
20. Place an X in one box to authorize the Department of Revenue to directly deposit your rebate
into your: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIRECT DEPOSIT. Banking rules do not permit direct deposits to bank accounts outside the U.S. If your bank account is outside the U.S.,
do not complete the direct deposit Lines 20, 21 and 22. The department will mail you a paper check. If your rebate will be going to a bank
account within the U.S., you have the option to have your rebate directly deposited. If you want the department to directly deposit your rebate
into your checking or savings account, complete Lines 20, 21 and 22.
21.
22.
Checking
Savings
22. Account number. Enter in boxes to the right. . . . . . . . . .
21. Routing number. Enter in boxes to the right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18. Rent Rebate. Enter the maximum rebate amount Compare this amount to line 17 and
from Table B for your income level here: (_______) enter the lesser amount to the right.
18.
Your Social Security Number
Your Name:
20.
CLAIMANT OATH: I declare that this claim is true, correct and complete to the best of my knowledge and belief, and this is the only claim filed by
members of my household. I authorize the PA Department of Revenue access to my federal and state Personal Income Tax records, my PACE records, my
Social Security Administration records and/or my Department of Human Services records. This access is for verifying the truth, correctness and
completeness of the information reported in this claim.
Claimant’s Signature Date
Spouse’s Signature Date
PREPARER: I declare that I prepared this return, and that it is to the best of my
knowledge and belief, true, correct and complete.
Preparers Signature, if other than the claimant Date
Preparers Name. Please print.
Preparers telephone number
Witnesses’ Signatures: If the claimant cannot sign, but only makes a mark.
1.
2.
Name of claimant’s power of attorney or nearest relative.
Please print.
Telephone number of claimant’s power of attorney or nearest relative
.
Home address of
claimant’s power of attorney or nearest relative.
Please print
.
City or Post Office State ZIP Code
An excessive claim with intent to defraud is a misdemeanor punishable by a maximum fine of $1,000, and/or imprisonment for up to one year
upon conviction. The claimant is also subject to a penalty of 25 percent of the entire amount claimed.
IV
TABLE A - OWNERS ONLY
INCOME LEVEL Maximum Standard
Rebate
$ 0 to $ 8,000 $650
$ 8,001 to $15,000 $500
$15,001 to $18,000 $300
$18,001 to $35,000 $250
TABLE B - RENTERS ONLY
INCOME LEVEL Maximum
Rebate
$ 0 to $ 8,000 $650
$ 8,001 to $15,000 $500
Enter the amount from Line 13 of
the claim form on this line and circle
the corresponding Maximum Rebate
amount for your income level.
Owners use Table A and Renters
use Table B.
23.
PA-1000 2021 05-21
(FI)
2105110056
2105110056
2105110056
MM/DD/YY
Please sign the PA-1000 after printing.
Please sign the PA-1000 after printing.
Please sign the PA-1000 after printing.
Please sign the PA-1000 after printing.
MM/DD/YY
Please sign the PA-1000 after printing.
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IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING