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 – RENTER ONLY
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.
Preparer’s Signature, if other than the claimant Date
Preparer’s Name. Please print.
Preparer’s 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)
