The claimant needs to fill in the appropriate spaces as necessary and enter required notes in the alphanumeric data field. When copies of documents are required, attach them to the Form W-RA that must be submitted. The page column indicates the page in the Schedule H and H-EZ instruction booklet that refers to the description.


No.

Description

Page
1Former spouse must pay a tax liability owed to the Department of Revenue per attached divorce judgment.6
2Sources of income reported on Line 8b of Schedule H (Line 5b of Schedule H-EZ) note is attached.10
3The distributive share of partnership, limited liability company (LLC), and tax-option (S) corporation depreciation, Section 179 expense, depletion, amortization, and intangible drilling costs is "None."13
4Car or truck expenses claimed using the standard mileage rate. Fill in the number of miles _____.13
5Adjusted basis of car or truck reached zero using standard mileage rate.13
6Car or truck expenses claimed using the actual expense method.14
7The computation of gain from the sale or exchange of a principal residence excluded from taxable income under section 121 of the Internal Revenue Code note is attached.12
8Claimant or spouse are age 65 or over and received no social security, SSI, or railroad retirement benefits.14
9All or part of a pension or annuity distribution includes a rollover or a tax-free exchange.11
10Nontaxable repaid amounts note is attached.11
11Very little or no household income note is attached.14
12Ownership of property document is attached.15
13Partial ownership interest was inherited with terms of the will requiring payment of all the property taxes. Copy of will is attached.15
14Personal property tax bill is for a mobile or manufactured home.15
15Two or more property tax bills. Drawing showing description, size, and location of each parcel is attached.15
16No lottery and gaming credit on property tax bill. Fill in the amount claimed $_______.__.15
17No lottery and gaming credit on property tax bill. Lottery and gaming credit not claimed by homeowner.15
18Landlord will not sign rent certificate. Rent verification is attached.16
19Claimant moved during the year. Note of the address of each dwelling and the dates lived there is attached.16
20Less than 12 months of property taxes and/or rent are claimed. Note of where claimant lived for the balance of the year is attached.16
21When more than one acre of land if rented, note from landlord indicating the amount of rent for home and one acre of land is attached.17
22Moved to tax-exempt housing. Claiming property taxes for up to 12 months after the move note is attached.17
23Married but separated all year: Claimant and spouse did not reside together at all during the year and neither the claimant nor claimant's spouse notified each other of marital property income.19
24Married but separated all year: Claimant and spouse did not reside together at all during the year and one or both spouses notified the other spouse of marital property income. Required information is attached.19
25Married but separated part of year: Required information is attached.20
26Marriage took place during year: Required information is attached.20
27Divorce took place during year: Claimant and spouse did not reside together at all during the year and neither the claimant nor claimant's spouse notified each other of marital property income.20
28Divorce took place during year: Claimant and spouse did reside together for part of the year and/or one or both spouses notified the other spouse of marital property income. Required information is attached.20
29Spouse died during year: Date of death - ___ / ___ / 201720
30Claimant resided in property address shown on tax bill but used a different mailing address on tax return.---
31Required notes and explanations in following data fields---
--Alphanumeric data field: You will be able to enter up to four lines of 80 characters per line. 


January 30, 2018