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MINNESOTA-REVENUE CRP <br /> Certificate of Rent Paid 2005 DOT 05 <br /> Eligible renters(see eligibility requirements below)may receive a refund based on property taxes paid on their principal place <br /> of residence in Minnesota and their income.For purpose of the property tax refund, 19 percent of the rent paid during the year <br /> is considered the portion paid for property tax. <br /> Your landlord is required to give each renter a completed Certificate of Rent Paid,Form CRP,no later than January 31,2006. <br /> Renters will need this CRP to apply for a property tax refund. <br /> Roommates:The landlord is required to give each unmarried renter living in a unit a separate CRP showing that each <br /> roommate paid an equal portion of the rent,regardless of the portion actually paid or whose names are on the lease. <br /> Renter's name and address of the unit rented Owner's or managing agent's name and address(including zip code) <br /> City of Orono Jane E.Lee,Metro Right of Way <br /> Minnesota Department of Transportation <br /> 3580 Wayzata.Blvd 1500 W County Rd 132 <br /> E Orono, MN 55356 Roseville,Mn 55113 <br /> Property ID number or parcel number County Number of units on this property <br /> 2713-055-210 Hennepin One <br /> Rented month day month day Number of adults living in unit <br /> From: 1 -01 2005 to:4 -30 2005 (count married couples as 1): <br /> One <br /> A. If the rental unit is a nursing home or health care facility,enter <br /> the amount paid for the renter GAMC or Medicaid................... <br /> B. If the landlord received Group Residential Housing(GRH)payments, <br /> enter the amount received from GRH on behalf of this renter...... <br /> 1 Rent paid to you by this individual renter or married couple for 2005.........................1 $5,264.52 <br /> If a government housing agency paid you part of the rent for this unit,check box❑, <br /> but do not include the amounts paid by the government agency in line 1. <br /> 2 The percentage for all renters is 19 percent(.19)................................................2 19% <br /> 3 Multiply line 1 by line 2.Renters:Include this amount on line 9 of your From M1PR..3 $1,000.26 <br /> 3 Landlord:I declare that thi4,Krti:cate is correct and complete to the best ofmy knowledge and belief <br /> + wn 's or gna ate Business Phone <br /> 651 582-1535 <br /> a Eligibility requirements for renters <br /> You may qualify for the property tax refund if all of the following conditions apply to you for 2005: <br /> • You were a full-year or part-year resident of Minnesota,and <br /> • You cannot be claimed as a dependent on someone else's 2005 federal income tax return,and <br /> • Your total household income is less than$47,350.(Household income is your federal adjusted gross income plus <br /> most nontaxable income.If you are single,use your income only;do not include the income of any other person <br /> living with you.Also,to arrive at your total household income,a subtraction is allowed if you have dependents or if <br /> you or your spouse are age 65 or older or disabled.) <br /> If you meet the above eligibility requirements,complete Form MI PR,Property Tax Refund Return,to determine the amount of <br /> your refund.You must include this CRP when you file your return. <br /> You can find Form MIPR and other tax-related information on our website at www.taxes.state.mn.us.Or,you can order forms <br /> by calling 651-296-4444.If you still have questions,call the department at 651-296-3781.TTY users,call Minnesota Relay at <br /> 711. <br /> If you qualify,complete and file Form M1PR.You must include this CRP when you file your return. <br /> Be sure to make copies of your Form M1PR and this form and keep them with your records. <br /> Stock No.1004850 <br />