Fill - Free fillable Form 2021: RENT REBATE PROGRAM PROPERTY TAX PENNSYLVANIA (Pennsylvania) PDF form

APPLICATION INSIDE

PENNSYLVANIA

RENT REBATE PROGRAM

2021

PROPERTY TAX

PA-1000 Booklet 06-21

Rebates for eligible seniors, widows,

widowers and people with disabilities.

HARRISBURG PA 17128-0503

www.revenue.pa.gov

IMPORTANT DATES

Application deadline: JUNE 30, 2022

Rebates begin: EARLY JULY, 2022

NOTE: The department may extend the

application deadline if funds are available.

2 PA-1000 Pennsylvania Property Tax or Rent Rebate Program

www.revenue.pa.gov

2021

WHAT IS THE PROPERTY TAX/RENT

REBATE PROGRAM?

A Pennsylvania program providing rebates on

property tax or rent paid the previous year by

income-eligible seniors and people with disabilities.

AM I ELIGIBLE?

The program benefits income-eligible Pennsylvanians

age 65 and older; widows and widowers age 50 and

older; and people with disabilities age 18 and older.

ELECTRONIC PTRR FILING

Pennsylvanians may electronically submit their

Property Tax/Rent Rebate program applications.

Visit mypath.pa.gov to access the Department of

Revenue’s electronic filing portal. Claimants who

submit their applications electronically will have the

benefit of automatic calculators and other user-

friendly features that are not available when filing a

paper application.

myPATH is safe, secure and more efficient. See

Page 18 or go to the department's website at

www.revenue.pa.gov/mypathinformation to learn

more about our electronic services.

CHECK APPLICATION STATUS

Applicants can check the status of their rebates

using the myPATH portal (mypath.pa.gov).

Be sure to include a valid phone number on your

application to receive updates automatically. The

department will make automated phone calls to

advise when your claim is received and again when

your claim is approved for payment. These calls

begin around April.

If you prefer to call to check the status of your appli-

cation, you may dial 1-888-PA-TAXES.

HOMEOWNERS

Income Maximum Rebate

$0 to $8,000 $650

$8,001 to $15,000 $500

$15,001 to $18,000 $300

$18,001 to $35,000 $250

RENTERS

Income Maximum Rebate

$0 to $8,000 $650

$8,001 to $15,000 $500

FORM AND INSTRUCTIONS

CHANGES

An additional item has been added to the list of

income that is not reported for Line 11g. All qualified

distributions from ABLE (Achieving a Better Life

Experience) Savings Programs are not to be includ-

ed as eligibility income by Property Tax or Rent

Rebate claimants.

The country code field has be changed from a

three-character field to a two-character field, See

the instructions for Country Code on Page 6 for

additional information.

DIRECT DEPOSIT

Get your rebate faster with direct deposit.

See Pages 12 and 13 for details.

STATE SUPPLEMENTARY PAYMENT RECIPIENTS

The State Supplementary Payment (SSP) is not included

on your SSA-1099 form. The Department of Human

Services will issue annual statements to verify your SSP

benefit. SSP is still considered reportable income. As with

other Social Security income, only half of the SSP income

needs to be included on Line 4 of the Property Tax/Rent

Rebate claim form.

SOCIAL SECURITY RECIPIENTS WITH

PA ADDRESSES

If you were a Pennsylvania resident for all of 2021, you do

not have to submit proof of your Social Security income

including Social Security retirement and Supplemental

Security benefits. The Social Security Administration

provides Social Security income information to the PA

Department of Revenue. The PA Department of Human

Services will provide State Supplementary Payment

information to the department.

However, you or the person who prepares your claim will

need these statements to correctly calculate the amount of

your rebate. If none of these documents are available, you

or your preparer will need to estimate the amount you

received during the year. If the dollar amount you provide

is not correct, the department will adjust the amount of

your rebate based upon income amounts reported directly

to the department by the Social Security Administration or

the Department of Human Services.

SOCIAL SECURITY RECIPIENTS WITHOUT

PA ADDRESSES

If your address in Social Security Administration records

was not a Pennsylvania address for 2021, you must submit

a copy of one of the following documents as proof of your

2021 Social Security income: Form SSA-1099 reporting

your 2021 Social Security benefits, a statement from

Social Security that reports the monthly or yearly Social

Security/Supplemental Security Income benefits you

received during 2021, or a bank statement showing the

amount of Social Security/Supplemental Security Income

benefits deposited into your account during 2021.

PHILADELPHIA RESIDENTS

Please read the special filing instructions on Page 11.

You are eligible for a Property Tax/Rent Rebate for claim

year 2021, if you meet the requirements in each of the

three categories below:

a. You were 65 or older as of Dec. 31, 2021;

b. You were not 65, but your spouse who lived with you

was 65 or older as of Dec. 31, 2021;

c. You were a widow or widower during all or part of

2021 and were 50 or older as of Dec. 31, 2021; or

d. You were permanently disabled and 18 or older

during all or part of 2021, you were unable to work

because of your medically determined physical or

mental disability, and your disability is expected to

continue indefinitely. If you received Supplemental

Security Income (SSI) payments, you are eligible for

a rebate if you meet all other requirements.

NOTE: If you applied for Social Security disability benefits

and the Social Security Administration did not rule in your

favor, you are not eligible for a Property Tax/Rent Rebate

as a disabled claimant.

When calculating your total eligible annual household

income, exclude one-half of your Social Security benefits

as shown in Box 5 of your SSA-1099 statement, one-half

of your Supplemental Security Income benefits, one-half of

your State Supplementary Payment benefits and one-half

of any Railroad Retirement Tier 1 benefits as shown on

Form RRB-1099.

a. Property Owners - Your total eligible annual house-

hold income, including the income that your spouse

earned and received while residing with you, was

$35,000 or less in 2021.

b. Renters - Your total eligible annual household

income, including the income that your spouse

earned and received while residing with you, was

$15,000 or less in 2021.

You must report all items of income, except the nonre-

portable types of income listed on Pages 8 and 9, whether

or not the income is taxable for federal or PA income tax

purposes.

NOTE: There may be differences between eligibility

income and PA-taxable income. Please see specific line

instructions for each category of income.

To file as a property owner, renter, or owner/renter, you must

meet all requirements for one of the following categories:

OWNER

a. You owned and occupied your home, as evidenced

by a contract of sale, deed, trust, or life estate held by

a grantee;

b. You occupied your home (rebates are for your

primary residence only); and

c. You or someone on your behalf paid the 2021

property taxes on your home.

BEFORE YOU BEGIN

ELIGIBILITY REQUIREMENTS

CATEGORY 1 – TYPE OF FILER

CATEGORY 2 – ELIGIBILITY INCOME

CATEGORY 3 – OWNER, RENTER OR

OWNER/RENTER

PA-1000 Pennsylvania Property Tax or Rent Rebate Program 3

RENTER

a. You rented and occupied a home, apartment, nursing

home, boarding home, or similar residence in

Pennsylvania;

b. Your landlord paid property taxes or agreed to make

a payment in lieu of property taxes on your rental

property for 2021 (see Page 12); and

c. You or someone on your behalf paid the rent on your

residence for 2021.

OWNER/RENTER

a. You owned, occupied, and paid property taxes for

part of the year and were a renter for part of the year;

b. You owned and occupied your home and paid

property taxes and paid rent for the land upon which

your home is situated; or

c. You paid rent for the home you occupied, and paid

property taxes on the land upon which your home is

situated.

CAUTION: As a renter, if you received cash public assis-

tance during 2021, you are not eligible for any rebate for

those months you received cash public assistance. Please

complete a PA-1000 Schedule D (enclosed in this booklet).

IMPORTANT: Please send photocopies, since the depart-

ment cannot return original documents. Print your Social

Security Number (SSN) on each proof document that you

submit with your claim form.

• If you are age 65 or older, provide proof of your age.

• If you are under age 65 and your spouse is age 65 or

older, provide proof of your spouse’s age.

• If you are a widow or widower age 50 to 64, provide

proof of your age and a photocopy of your spouse’s

death certificate.

• If you are permanently disabled, age 18 to 64, you must

provide proof of your age and proof of your permanent

disability.

PROOF OF AGE

NOTE: If you receive Social Security or SSI benefits and

have proven your age with the Social Security

Administration, you do not need to submit proof of age.

IMPORTANT: The department accepts photocopies of the

following documents as proof of your age. Do not send

your original documents since the department cannot

return original documents.

• Birth certificate

• Blue Cross or Blue Shield 65 Special Card

• Church baptismal record

• Driver’s license or PA identification card

• Hospital birth record

• Naturalization/immigration paper, if age is shown

• Military discharge paper, if age is shown

• Medicare card

• PACE/PACENET card

• Passport

The department will not accept a Social Security card or

hunting or fishing license as proof of age.

If you have questions on other types of acceptable

documents, please call the department at 1-888-222-9190.

PROOF OF DISABILITY

• For Social Security disability, SSI permanent and total

disability, Railroad Retirement permanent and total

disability, or Black Lung disability, provide a copy of your

award letter.

• For Veterans Administration disability, provide a letter

from the Veterans Administration stating that you are

100 percent disabled.

• For Federal Civil Service disability, provide a letter from

Civil Service stating that you are 100 percent disabled.

• If you do not qualify under any of the disability programs

mentioned above, did not apply for Social Security

benefits, or do not have a letter from the Veterans

Administration or Civil Service Administration, you must

submit a Physician’s Statement of Permanent Disability

(PA-1000 PS), enclosed in this booklet. The form must

describe your disability as permanent and your

physician must sign the statement to certify that the

information is true and accurate to the best of his/her

knowledge and belief.

IMPORTANT: The Physician’s Statement of Permanent

Disability cannot be used if you were denied Social

Security disability. The Department of Revenue has the

legal authority to require additional evidence that you are

permanently disabled and eligible for a rebate.

HOUSEHOLDS WITH MORE THAN

ONE QUALIFIED CLAIMANT

Only one member of your household may file a claim even

if more than one person qualifies for a rebate. If someone

other than your spouse appears on the deed or the lease,

please complete a PA-1000 Schedule F (enclosed in this

booklet). You may apply for only one rebate each year.

DECEASED CLAIMANT

To be eligible for a rebate, the claimant must have lived at

least one day of a claim year, owned and occupied and

paid taxes or rented and occupied and paid rent for the

claim year during the time period the claimant was alive.

The property tax paid for a deceased claimant will be

prorated based upon the number of days the claimant lived

during the claim year. See Schedule A for the calculation of

the prorated property tax rebate.

To determine if a deceased claimant is eligible for a rebate, a

deceased claimant’s claim form must also include an

annualized income amount in the calculation of total

household income. See Schedule G, specifically the

instructions for Line 11g, for information on the calculation of

PROOF DOCUMENTS THAT FIRST

TIME FILERS MUST SUBMIT

4 PA-1000 Pennsylvania Property Tax or Rent Rebate Program

annualized income to be included in household income. A

copy of the death certificate must also be included with the

claim form.

A surviving spouse, estate or personal representative may

file a claim on behalf of a deceased claimant. A personal

representative can also have a previously filed rebate issued

in his or her name, instead of the name of the decedent, in

certain circumstances. Please see sections entitled

SURVIVING SPOUSE, AN ESTATE, and PERSONAL

REPRESENTATIVE for details.

SURVIVING SPOUSE

The surviving spouse can file the completed claim and

include a copy of the death certificate and a letter stating that

he/she was the spouse of the claimant at the time of death.

The surviving spouse may sign on the claimant’s signature

line.

If the surviving spouse is eligible to file a claim, he/she can

file under his/her own name instead of submitting a claim

using the deceased individual’s claim form.

The surviving spouse should print his/her name, address,

and Social Security Number (SSN) in Section I, and follow

the filing instructions. The surviving spouse should furnish

proof required for a first time filer. Do not use the label the

department sent to the decedent in the booklet. The surviving

spouse should enter the deceased spouse’s SSN and name

in the spouse information area, and fill in the oval “if Spouse

is Deceased”, located in the area next to the Spouse’s SSN

on the claim form.

AN ESTATE

The executor or the administrator of the claimant’s estate

may file the claim and submit a Short Certificate showing the

will was registered or probated. When there is no will and

there are assets (an estate), submit a copy of the Letters of

Administration. A Short Certificate or Letters of Administration

can be obtained from the county courthouse where the death

is recorded. The person filing the claim form on behalf of the

deceased person may sign on the claimant’s signature line.

PERSONAL REPRESENTATIVE

If a person dies and there is no will, the will has not been reg-

istered or probated or there is no estate, then a personal rep-

resentative may file a claim on behalf of an eligible decedent.

A decedent’s personal representative must submit a copy of

the decedent’s death certificate, a DEX-41, Application for

Refund/Rebate Due the Decedent, and a receipted copy of

the decedent’s funeral bill showing that the personal repre-

sentative personally paid the decedent’s funeral expenses in

an amount that is greater than or equal to the amount of the

property tax/rent rebate to which the decedent is entitled.

If a person dies after filing a claim and there is no will, or if

the will has not been registered or probated, or there is no

estate, then a personal representative can also request

that the department change the rebate to be issued into

his/her name. In cases where the rebate check has been

received but cannot be cashed, the check must be

returned with a request to have the rebate issued in the

name of the personal representative. The decedent’s per-

sonal representative must submit a copy of the decedent’s

death certificate, a DEX-41, Application for Refund/Rebate

Due the Decedent, and a receipted copy of the claimant’s

funeral bill showing that the personal representative

personally paid the funeral expenses in an amount that is

greater than or equal to the amount of the property tax/rent

rebate to the claimant is entitled.

The DEX-41, Application for Refund/Rebate Due the

Decedent, can be obtained by visiting the department’s

website at www.revenue.pa.gov or by using one of the

department’s Forms Ordering Services found on Page 18.

If you have any questions regarding the filing of a claim on

behalf of a deceased claimant, please call the department

at 1-888-222-9190.

PRIVACY NOTIFICATION

By law, (42 U.S.C. § 405(c)(2)(C)(i); 61 Pa. Code §117.16)

the Pennsylvania Department of Revenue has the authority

to use the Social Security Number (SSN) to administer the

Property Tax or Rent Rebate Program, the Pennsylvania

personal income tax and other Commonwealth of Pennsyl-

vania tax laws. The department uses the SSN to identify

individuals and verify their incomes. The department also

uses the SSN to administer a number of tax-offset and

child-support programs federal and Pennsylvania laws

require. The commonwealth may also use the SSN in

exchange-of-tax-information agreements with governmental

authorities.

Pennsylvania law prohibits the commonwealth from

disclosing information that individuals provide on income

tax returns and rebate claims, including the SSN(s), except

for official purposes.

You must fill in your Social Security Number and enter

your county and school district codes even if using

the preprinted label. If you are not using software or

myPATH to prepare your claim and your label is correct,

place your label in Section I. If you or your preparer are

using software or myPATH to prepare your claim, or if any

information on the preprinted label is incorrect, discard the

label. If not using a label, follow the instructions for printing

letters and numbers and completing your name and

address.

If your spouse lived in a nursing home the entire year do

not include his/her Social Security Number on the claim

form. He or she may qualify for a separate rebate on the

rent paid to the nursing home.

IMPORTANT TIPS: There are two lines to enter your

address. For the First Line of Address, enter the street

address. If the address has an apartment number (APT),

suite (STE), floor (FL) or rural route number (RR), enter

PA - 1000 FILING INSTRUCTIONS

SECTION I - SOCIAL SECURITY NUMBER, NAME,

ADDRESS AND RESIDENCE INFORMATION

PA-1000 Pennsylvania Property Tax or Rent Rebate Program 5

it after the street address. If the street address and the

apartment number, suite, etc. do not fit on the First Line of

Address, enter the street address on the Second Line of

Address and the apartment number, suite, etc. on the First

Line of Address. For the Second Line of Address, enter the

post office box, if applicable. If there is no post office box,

leave the Second Line of Address blank.

The U.S. Postal Service prefers that the actual delivery

address appears on the line immediately above the city,

state and ZIP code. Do not include any punctuation such

as apostrophes, commas, periods and hyphens.

• Use black ink. Another color such as red ink will delay

the processing of your rebate claim.

• Do not use pencil or pens labeled as gel pens or any red

ink.

• Print all information on your claim neatly inside the boxes.

• Use upper case (capital) letters. Use a blank box to

separate words.

• Print one letter or number in each box when entering

your Social Security Number, name, address, dollar

amounts, and other information. If your name, address,

or city begins with Mc, Van, O’, etc., do not enter a

space or a punctuation mark.

• Completely fill in all the appropriate ovals on your

claim form.

As a claimant, you must provide your birth date, telephone

number, county code, school district code, and, if applicable,

your spouse’s Social Security Number, birth date, and name.

If your spouse is deceased, completely fill in the oval “If

Spouse is Deceased” in Section I of the form.

COUNTRY CODE

If your current mailing address is in the United States of

America, you are not required to enter a country code.

The department will automatically include the correct

code for you. However, if - you lived at least part of the

year in Pennsylvania; you meet the eligibility require-

ments for a property tax or rent rebate; and your cur-

rent mailing address is in any other country, you must

enter the alphabetic abbreviation for your mailing

address country. The list of alphabetic abbreviation

country codes can be found at https://www.irs.gov/e-

file-providers/foreign-country-code-listing-for-

modernized-e-file under the country codes menu

selection.

COUNTY & SCHOOL CODES

You must enter the two-digit county code and five-digit

school district code for where you lived on Dec. 31, 2021,

even if you moved after Dec. 31, 2021. Using incorrect

codes may affect your property tax rebate.

IMPORTANT: The lists of county and school district names

and the respective codes are on Pages 15, 16 and 17. If

you do not know the name of the county or school district

where you reside, you can either 1) check the county and

school property tax bills used to complete this claim if you

are a property owner, or 2) obtain this information from the

Online Customer Service Center at www.revenue.pa.gov.

NOTE: Be sure to include your phone number when com-

pleting the claim form. The department will make automat-

ed phone calls to advise when claims are received and

again when they are approved for payment.

Line 1 - Please fill in the oval that shows your correct

filing status. Fill in only one oval. Filling in more than one

oval may reduce the amount of your rebate.

(P) Property Owners: Fill in this oval if you owned and

occupied your home for all or part of 2021 and did not rent

for any part of the year. If your deceased spouse’s name is

on your deed or tax bills, include the decedent’s Social

Security Number and name.

(R) Renters: Fill in this oval if you rented and occupied

your residence for all or part of 2021.

(B) Owner/Renter: Fill in this oval if you owned and occu-

pied your residence for part of 2021, and also rented and

occupied another residence for the rest of 2021, or if you

owned your residence and rented the land where your

residence is located.

EXAMPLE: John pays property taxes on a mobile home

that he owns and occupies. His mobile home is on land

that he leases. John may claim a property tax rebate on

the mobile home and a rent rebate on the land. See Pages

9, 11 and 12 for documents you must send as proof of

property taxes or rents paid.

Line 2 - Certification. Please read each description and

select the type of filer that applies best to your situation

as of Dec. 31, 2021. A surviving spouse age 50 to 64 is

eligible for a rebate as a widow or widower, while a

surviving spouse who is 65 or older can file as a claimant.

A surviving spouse under 50 may be able to file a claim for

a deceased claimant if the deceased was 65 or older.

Please complete the claim form using your Social Security

Number, name and address, and supply all appropriate

documentation.

a. Claimant age 65 or older

b. Claimant under age 65, with a spouse age 65 or older

who resided in the same household (You must submit

proof of your spouse’s age the first time you file.)

c. Widow or widower, age 50 to 65 (If your most recent

marriage ended in divorce, you do not qualify as a

widow/widower.)

d. Permanently disabled and age 18 to 64

Sample

M C D O E J O H N

A P T 4 5 6

1 2 3 A N Y S

H A R R I S B U R G P A

1 7 1 2 8

J A N E 2 2 2 7 5

SECTION II - FILING STATUS CATEGORIES

6 PA-1000 Pennsylvania Property Tax or Rent Rebate Program

See Page 4 for acceptable proof of age documents.

Line 3 - If you are filing on behalf of a decedent (a

claimant who died during the claim year who otherwise

would have been an eligible claimant under a, b, c or d

for Line 2 above), completely fill in the oval. The type

of claimant under which the decedent qualifies under

Line 2 above must also be included. A copy of the death

certificate must be submitted and Schedule G must be

completed.

You must report the total household income you earned

and/or received during 2021 for each category, which

includes your spouse’s income earned and/or received

while residing with you.

All claimants must submit proof of annual income.

IMPORTANT: The department reserves the right to

request additional information or make adjustments to

federal data if credits or deductions were taken to reduce

income.

CAUTION: Spouses may not offset each other’s income

and losses.

The department has the legal authority to require evidence

of the income you report on your claim. The following lists

the kinds of income you must report and the documents

you must submit as proof of the reported income. You must

include the income that your spouse received while

residing with you. See Pages 8 and 9 for a list of the kinds

of income that you do not need to report.

NOTE: Print your Social Security Number on each Proof

Document that you submit with your claim form.

Line 4 - Include one-half of your 2021 Social Security

Benefits as shown in Box 5 of your benefit statement

SSA-1099, one-half of your 2021 SSI, one-half of your

2021 Social Security Disability Income, and one-half of

your 2021 State Supplementary Payment. No documenta-

tion is required, if using a PA address.

Line 5 - Include one-half of your Railroad Retirement

Tier 1 Benefits. Submit a copy of form RRB-1099.

CAUTION: The total income from old age benefit

programs from other countries, such as Service Canada

Old Age Security, must be converted into U.S. dollars and

reported on Line 6.

Line 6 - Include the gross amount (not the taxable

amount) of pensions, annuities, Individual Retirement

Account distributions, Tier 2 Railroad Retirement Benefits,

and Civil Service Disability Benefits. Do not include Black

Lung Benefits federal veterans’ disability payments, or

state veterans’ benefits. State veterans’ benefits include

service connected compensation or benefits of any kind

provided to a veteran or unmarried surviving spouse

paid by a commonwealth agency or authorized under

the laws of the commonwealth. Submit photocopies of

pension/annuity benefits statements along with other

forms 1099 showing income for 2021.

IMPORTANT: Do not include rollovers from Individual

Retirement Accounts and employer pensions. However,

proof must be provided. Proof includes, but is not limited

to, a federal Form 1099-R showing a rollover or other

documentation indicating that the distribution was rolled

into a new account.

If you have one or more distributions from annuity, life

insurance or endowment contracts reported on Form

1099-R that are included as interest income on your PA-40

Personal Income Tax Return, please write “Included as

Interest Income on PA-40” across the top of any Form

1099-R for such distributions and include copies of all your

Forms 1099-R with your claim form.

Line 7 - Report interest and dividends received or credited

during the year, whether or not you actually received

the cash. If you received dividends and capital gains

distributions from mutual funds, report the capital gains

distributions portion of the income as dividends, not

as gains from the sale or exchange of property. Include

interest received from government entities. You must also

include all tax-exempt interest income from direct obliga-

tions of the U.S. government, any state government, or any

political subdivision thereof in the amount shown on Line 7.

SUBMIT THE FOLLOWING:

• A copy of your federal Form 1040 Schedule B or your

PA-40 Schedule A and/or B; or copies of any federal

Forms 1099 you received; OR

• A copy of the front page of your PA or federal income tax

return verifying the income reported on Line 7.

IMPORTANT: If you received capital gains distributions

from a mutual fund, you must use PA Schedule B or the

front page of your PA tax return to verify your income. If

you have PA tax-exempt interest income, you must include

federal Form 1040 Schedule B along with a copy of the

front page of your federal tax return.

Line 8 - Include gains or losses you realized from the sale

of stocks, bonds, and other tangible or intangible property

as well as any gains or losses realized as a partner in a

partnership or shareholder in a PA S corporation. Do not

include capital gains distributions from mutual funds

required to be reported on Line 7.

NOTE: The nontaxable gain on the sale of your principal

residence must also be reported on this line. If you realized

a loss from the sale of your principal residence, this loss

may be used to offset any other gains you realized from

the sale of tangible or intangible property. However, any

net loss reported on this line cannot be deducted from any

other income. You may also submit photocopies of each

PA Schedule RK-1, PA Schedule NRK-1 or federal

Schedule K-1 that shows your gains or losses for each

partnership or PA S corporation.

Submit a copy of your federal Form 1040 Schedule D, a

copy of your PA-40 Schedule D, or copies of any federal

Forms 1099 you received which will verify any gains or

losses you realized. If you received capital gains distribu-

tions from mutual funds, do not include a copy of federal

SECTION III - LINES 4 THROUGH 18

PA-1000 Pennsylvania Property Tax or Rent Rebate Program 7

Form 1040 Schedule D. You must include a copy of your

PA-40 Schedule D.

If you sold your personal residence during this claim

year, submit a statement showing the sale price less

selling expenses, minus the sum of the original cost and

permanent improvements.

CAUTION: You may only use losses from the sale or

exchange of property to offset gains from the sale or

exchange of property.

Line 9 - Include net rental, royalty, and copyright income or

loss realized during 2021 from property owned and rented

to others, oil and gas mineral rights royalties or income

received from a copyright as well as any net income or loss

realized as a partner in a partnership or shareholder in a

PA S corporation.

CAUTION: You may only use rental losses to offset

rental income.

IMPORTANT: If you receive income from the rental of a

portion of your own home, you must complete and submit

a PA-1000 Schedule E (enclosed in this booklet). Submit a

copy of your federal Form 1040 Schedule E, Part I, or

PA-40 Schedule E from your income tax return. You may

also submit photocopies of each PA Schedule RK-1,

PA Schedule NRK-1 or federal Schedule K-1 that shows

your net income or loss from rents, royalties, patents and

copyrights for each partnership or PA S corporation.

Line 10 - Include net income or loss from a business,

profession, or farm, and net income or loss you realized

as a partner in a partnership or a shareholder in a PA

S corporation.

CAUTION: You may only use business losses to offset

business income.

IMPORTANT: If you operate your business or profession at

your residence, you must complete and submit a PA-1000

Schedule E (enclosed in this booklet).

Submit a photocopy of each federal Form 1040 Schedule

C or F, or PA-40 Schedule C or F from your income tax

return. You may also submit photocopies of each PA

Schedule RK-1, PA Schedule NRK-1, or federal Schedule

K-1 that shows your income or loss for each business.

Lines 11a - 11g - Other Income - Complete Lines 11a

through 11g to report all other income that you and your

spouse earned, received, and realized.

For each category of income on Lines 11a through 11g,

you must submit proof, such as photocopies of Forms

W-2, Department of Human Services cash assistance

statements, your federal or PA income tax returns, and any

other documents verifying income.

Line 11a. - Gross salaries, wages, bonuses, commis-

sions, and estate or trust income not included in business,

profession, or farm income.

Line 11b. - Gambling and lottery winnings, including

PA Lottery, Powerball and Mega Millions winnings, prize

winnings, and the value of other prizes and awards. (A

PA-40 Schedule T must be submitted to verify these winnings,

as well as a W-2G to document PA Lottery winnings.)

Line 11c. - Value of inheritance, alimony, and spousal

support money.

Line 11d. - Cash public assistance/relief, unemployment

compensation, and workers’ compensation benefits,

except Section 306(c) benefits.

Line 11e. - Gross amount of loss of time insurance benefits,

disability insurance benefits, long-term care insurance

benefits (if received directly by the claimant), and life

insurance benefits and proceeds, except the first $5,000 of

the total death benefit payments.

Line 11f. - Gifts of cash or property totaling more than

$300, except gifts between members of a household.

Line 11g. - Miscellaneous income and annualized

income amount. Include any income not identified above

prior to the calculation of annualized income. If a claimant

died during the claim year, an annualized income amount

must also be included. To calculate the annualized income

amount, complete Schedule G. When adding amounts for

Line 3 of Schedule G, do not add any negative amounts

reported on Lines 8, 9 or 10.

Do not report the following income:

• Medicare or health insurance reimbursements;

• Food stamps, surplus foods, or other such non-cash

relief supplied by a governmental agency;

• Property Tax/Rent Rebate received in 2021;

• The amount of any damages due to personal injuries or

sickness. Damages include Black Lung benefits and

benefits granted under Section 306(c) of the Workers’

Compensation Security Fund Act (relating to Schedule

of Compensation for disability from permanent injuries

of certain classes);

• Payments provided to eligible low-income households

under the commonwealth’s Low Income Home Energy

Assistance Program;

• Payments received by home providers of the domiciliary

care program administered by the Department of Aging,

except those payments in excess of the actual expenses

of the care;

• Disability income received by disabled children in the

household;

• Federal veterans’ disability payments or state veterans’

benefits received by the veteran or unmarried surviving

spouse;

• The difference between the purchase price of your

residence and its selling price, if you used the proceeds

from the sale to purchase a new residence. This new

residence must be your principal residence;

• Federal or state tax refunds;

• Spouse’s income earned or received while not living

with you;

• Public Assistance benefits received by children in the

household, even though the check is issued in

claimant’s name;

8 PA-1000 Pennsylvania Property Tax or Rent Rebate Program

• Qualified distributions from ABLE (Achieving a Better

Life Experience) Savings Programs;

• Federal stimulus or economic impact payments;

• STRIVE Program credits;

• Child support; and

• Individual Retirement Account and employer pension

rollovers (must provide a copy of federal Form 1099-R

indicating rollover or other supporting documentation).

CAUTION: If a claimant had significant income that is not

typically received in equal amounts throughout the claim

year, or if the number-of-days method does not accurately

calculate the annualized income, the claim may be filed

using an alternative method for determining the annualized

income amount to be included on Line 11g. A worksheet

must be included to show how the amount of annualized

income was determined in those instances. The worksheet

must clearly show how the income was determined and an

explanation of the reason for deviating from the Schedule

G method. Examples of when the claim would be filed

using an alternative method would include instances

where there is income from a one-time event such as a

gain on the sale of stock, lump sum payments from an IRA

or annuity, an amount is reported as an inheritance or a

payment is received as a beneficiary on a life insurance

policy. Proof of the deviation from the number-of-days

method may be required by the department. The depart-

ment will accept reasonable methods of calculating the

annualized income amount.

Line 12 - If you and/or your spouse received benefits

from the federal Civil Service Retirement System (CSRS)

as (a) retired federal civil service employee(s) or as a sur-

viving spouse, you may reduce your total eligibility income

by 50% of the average retired worker Social Security pay-

ment for 2020. The average retired worker Social Security

payment for 2020 is $9,514. Enter $9,514 on Line 12 only

if you include CSRS benefits in Line 6. If both you and your

spouse received CSRS benefits, or if you received your

own CSRS benefits and CSRS benefits as a surviving

spouse, enter $19,028 on Line 12. Otherwise, enter $0.

Line 13 - Add the positive income figures reported on

Lines 4 through 11g, subtract the amount on Line 12 (if

applicable) and enter the net result on Line 13 and 23. Do

not include losses reported on Lines 8, 9 and/or 10.

IMPORTANT: If you have over $35,000 of income claimed

on Line 13, you are not eligible for either Property Tax or

Rent Rebate relief under this program.

Line 14 - For Property Owners Only

Before completing Line 14 of the claim form, complete any

schedules listed in the instructions for this line. If you must

complete more than one schedule, you must complete

them in alphabetical order. If one schedule does not apply

to you, skip it, and go to the next schedule. You must carry

forward, as the total tax paid, the last amount shown on the

previous schedule you complete to the next schedule

you complete.

Enter the total amount of the property taxes paid for

your primary residence, or the amount shown as eligible

property taxes paid on the last schedule completed.

IMPORTANT: If you do not enter the amount of all taxes

paid on the primary residence, you will limit the

department’s ability to determine your eligibility for and

amount of a supplemental rebate. See Page 14 for more

information on supplemental rebates.

You must deduct interest or penalty payments, municipal

assessments, per capita taxes, or occupation taxes included

in your payment. If you paid early and received a discount,

you enter the amount you actually paid on Line 14. You

must also deduct other charges included in your tax bills.

See taxes that are not acceptable on Page 11.

If your name does not appear on the receipted tax bills,

you must submit proof of ownership. Examples of proper

proof are: a copy of the deed or a copy of the trust

agreement, will, or decree of distribution if you inherited

your property. If your address is not on your receipted

property tax bill or mortgage statement, you also must

submit a letter from your tax collector or mortgage company

verifying your home address.

NOTE: If your tax bills include a name and/or names other

than yours and your spouse’s, you must complete PA-1000

Schedule F or submit proof that you are the sole owner of

the property.

Include only the property tax on the amount of land that is

necessary for your personal use.

PA-1000 Schedule A - If you owned and occupied your

home for less than the entire year of 2021 or a claim

is being filed on behalf of a deceased owner who died

during 2021.

PA-1000 Schedule B - If you were a widow or widower

age 50 to 64 who remarried in 2021.

PA-1000 Schedule E - If you used part of your residence

for a purpose other than living quarters in 2021.

PA-1000 Schedule F - If your deed shows owners other

than your spouse.

As proof of property tax paid, homeowners must

provide photocopies of one of the following real estate

documents:

• All 2021 real estate tax bills that have been marked

“paid” by the tax collector (see the instructions beginning

on this page for the proper calculation of the amount on

Line 14). If you paid your taxes in quarterly installments,

a tax bill must be submitted for each period. For tax bills

that are not marked paid by the tax collector, the depart-

ment will accept a photocopy of both sides of the

cancelled check along with a copy of the tax bill;

• Your year-end mortgage statement showing the amount

of real estate taxes paid;

• A letter signed by the tax collector certifying that you

paid your 2021 real estate taxes. The letter should also

declare the total tax does not include nuisance taxes or

penalty; OR

PA-1000 Pennsylvania Property Tax or Rent Rebate Program 9

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.

III

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

Filing on behalf of a

decedent

Dollars Cents

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

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

2105010017

Claimant’s Birthdate

M M D D Y Y

Spouse’s Birthdate

M M D D Y Y

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

PLACE LABEL HERE

Daytime Telephone Number

2105010017

School District CodeCounty Code

Country Code

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.

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.

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

( )

2105120014

Fill in this oval if your spouse is deceased.

If your label

is correct,

place it here.

Discard label if

it is not correct

and fill in all

data in Section I.

If you were both a Property

Owner and a Renter,

complete Lines 14 through 19

Fill in your Social Security Number.

Fill in only one oval for Line 1.

Fill in only one oval for Line 2.

Sample

Report your total Social

Security, SSI, and SSP benefits

here. Divide the total by 2 and

enter the result on Line 4.

Enter the total of Lines 4

through 11g, less Line 12.

Report your total Railroad

Retirement Tier 1 benefits here.

Divide the total by 2 and enter

the result on Line 5.

PA-1000 COMPLETION SAMPLE

Property Owners

complete Lines

14 and 15.

Renters complete

Lines 16, 17 and 18.

If you want your

rebate directly

deposited, complete

Lines 20,

21 and 22.

Claimant signs here.

Fill in School District Code

(see Pages 16 and 17). Fill in

County Code (see Page 15). Fill

in Country Code if applicable

(see Page 6).

10 PA-1000 Pennsylvania Property Tax or Rent Rebate Program

Enter your Routing Number

here (direct deposit only)

Enter your Account Number

here (direct deposit only)

Fill in this oval on behalf

of decedent.