ADOR 10417 (22) Use Form 201 if you rented in 2022 and are claiming the property tax credit. This certificate shows what portion of your rent money went to pay taxes. Your landlord or designated agent must sign and complete this form in order for you to qualify for your credit. USE BLACK INK ONLY. Part 1 To be Completed by Tenant First Name and Initial - also give spouse’s name and initial Last Name Social Security Number Part 2 To be Completed by Your Landlord 1 Name of Landlord 2 Number and Street Address 3 City County State ZIP Code 4 Business Name of Rental Property (if applicable) 5 Number and Street Address 6 City County State ZIP Code 7 If any of your tenants received rent subsidies in 2022, check this box................................................. 7  8 If the property was exempt from property tax during 2022, check this box........................................... 8  If you checked box 8, tenants may not claim the property tax credit on any form or schedule. 9 If you occupy any portion of the property you rent or lease to others, check this box.......................... 9  10 Enter property tax factor........................................................................................................................ 10 • Signature of Responsible Party: I declare that I have examined this statement and to the best of my knowledge and belief, it is correct and complete.

11

SIGNATURE OF OWNER, LESSOR, OR MANAGER OF RENTAL PROPERTY DATE

12

PRINT OR TYPE NAME OF SIGNING PARTY

OWNER’S OR PROPERTY MANAGER’S PHONE NUMBER

(for verification of information only) Part 3 Tenant Claiming Property Tax Credit Must Complete Part 3

13 Enter total rents paid in 2022 not including subsidies.......................................................................... 13 00

14 Enter property tax factor from Part 2, line 10....................................................................................... 14 •

15 Multiply line 13 by line 14. Enter the result here and on Form 140PTC, line 13. This is the amount of rent which constitutes property taxes................................................................................. 15 00 HOW TO USE THIS FORM IMPORTANT: For 2022, be sure to have your landlord complete this form well before April 18, 2023 or request an extension (Arizona Form 204) to protect the credit. Landlords may not have the information immediately available. The extension will give you until October 16, 2023 to file Form 140PTC and Form 210. Homeowners: If you own the home you live in, do not use this form. Homeowners claiming a property tax credit rebate must send a statement of property taxes paid rather than this form. See Form 140PTC instructions. Renters Seeking a Tax Rebate on Form 140PTC: 1. Ask your landlord to complete Part 2 of this form. 2. Complete Parts 1 and 3 if you qualify. See instructions. 3. Use this information to complete your Form 140PTC. 4. Include this certificate with your Form 140PTC and keep a copy for your tax records. Arizona Form 201 Renter’s Certificate of Property Taxes Paid 2022 Print Form