ELIGIBILITY. IF YOU ANSWER NO TO ANY OF THESE QUESTIONS, YOU ARE NOT ELIGIBLE FOR THIS CREDIT. STOP HERE. DO NOT COMPLETE THE REST OF THIS FORM. A Were you domiciled in Rhode Island for all of 2021?.................................................................................. A B In 2021 did you live in a household or rent a dwelling that was subject to property tax?............................ B C Are you current for property taxes or rent due on the homestead for 2021 and all prior years?................. C PART 2 Enter your total household income from page 2, line 32............................................................................. 1b Enter your date of birth ............................ 1d Enter spouse's date of birth ..................... 1e Were you or your spouse disabled and receiving Social Security Disability payments during 2021? 1g PART 3 TO BE COMPLETED BY HOMEOWNERS ONLY– ATTACH A COPY OF YOUR 2021 PROPERTY TAX BILL TO 1040H FORM 2 Enter the amount of property taxes you paid or will pay for 2021............................................................... 3 2 Using your household income from line 1b enter percentage from the computation table located on pg 3 4 3 Multiply amount on line 1b by percentage on line 3.................................................................................... 5 4 Tentative credit. Subtract line 4 from line 2. If line 4 is greater than line 2, enter zero.............................. 5 PROPERTY TAX RELIEF. Line 5 or $415.00, whichever is LESS.............................................................. 6 6 PART 4 TO BE COMPLETED BY RENTERS ONLY– ATTACH A COPY OF YOUR 2021 LEASE OR 3 RENT RECEIPTS TO 1040H LANDLORD INFORMATION (REQUIRED) Name: Address: Telephone number: 7 Enter the amount of rent you paid in 2021.................................................................................................. 8 7 Multiply the amount on line 7 by twenty (20) percent (0.2000).................................................................... 8 Using your household income from line 1b enter percentage from the computation table located on pg 3 9 9 Multiply amount on line 1b by percentage on line 9.................................................................................... 10 10 11 Tentative credit. Subtract line 10 from line 8. If line 10 is greater than line 8, enter zero.......................... 11 PROPERTY TAX RELIEF. Line 11 or $415.00, whichever is LESS............................................................ 12 12 PROPERTY TAX RELIEF. Line 6 or line 12, whichever applies. Enter here and on Form RI-1040, line 14c....... 13 13 b c e YES NO / / / / ELIGIBILITY HOME OWNERS INFO D Were you or your spouse 65 years of age or older and/or disabled as of December 31, 2021?................ D E Was your 2021 total household income from page 2, line 32 $30,000 or less?.......................................... E RENTERS 1f Indicate the number of persons in your household ..................................................................................... f Enter the number of persons from 1f who are dependents under the age of 18........................................ g % % YES NO YES NO YES NO YES NO YES NO Enter the total amount of public assistance received by all members of your household........................... 1a 1a PART 1 ADDITIONAL INFORMATION - ATTACH A COPY OF YOUR 2021 SOCIAL SECURITY AWARD LETTER OR FORM 1099 TO 1040H FORM RETURN MUST BE SIGNED - SIGNATURE IS LOCATED ON PAGE 2 Mailing address: RI Division of Taxation, One Capitol Hill, Providence, RI 02908-5806 CREDIT State of Rhode Island Division of Taxation 2021 Form RI-1040H Rhode Island Property Tax Relief Claim First name MI Last name Spouse’s first name MI Last name Mailing address Your social security number Spouse’s social security number City, town or post office City or town of legal residence Home Address if using a PO Box or if your Mailing Address is different from Home Address Email address Deceased? ZIP code Yes Yes Yes State Mailing address Your social security number City or town of legal residence Home Address if using a PO Box or if your Mailing Address is different from Home Address Email address Deceased? ZIP code State Daytime telephone number City, town or post office New address? Deceased? Your first name MI Last name Suffix Suffix Your social security number Spouse’s social security number Daytime telephone number City or town of legal residence Home Address if using a PO Box or if your Mailing Address is different from Home Address Email address ZIP code Yes Yes Yes Home Address if using a PO Box or if your Mailing Address is different from Home Address Email address New address? Deceased? Deceased? 21100299990101

PART 5 ENTER ALL INCOME RECEIVED BY YOU AND ALL OTHER PERSONS LIVING IN YOUR HOUSEHOLD Sale or exchange of property from Federal Form 1040 or 1040-SR line 7 or Federal Form 1040 or 1040- SR Schedule 1, line 4.................................................................................................................................. 19 19 20 IRA distributions, and pensions and annuities from Federal Form 1040 or 1040-SR, line 4a and 5a........ 20 21 Rental real estate, royalties, S corps, trusts, etc. from Federal Form 1040 or 1040-SR, Sch 1, line 5........ 21 22 Farm income or loss from Federal Form 1040 or 1040-SR, Schedule 1, line 6.......................................... 22 23 Unemployment compensation from Federal Form 1040 or 1040-SR, Schedule 1, line 7............................... 23 Social security benefits (including Medicare premiums) taxable and nontaxable, and Railroad Retirement Benefits from Federal Form 1040 or 1040-SR, line 6a............................................................. 24 24 Other income from Federal Form 1040 or 1040-SR, Schedule 1, line 9..................................................... 25 25 26 Total income from Federal 1040 or 1040-SR- taxable and nontaxable. Add lines 14 through 25.................... 26 27 Deductions from Federal Form 1040 or 1040-SR, line 10 and 12b.................................................................... 27 28 Adjusted income. Subtract line 27 from line 26.......................................................................................... 28 HOUSEHOLD INCOME WORKSHEET Wages, salaries, tips, etc. from Federal Form 1040 or 1040-SR, line 1............................................................. 14 14 15 Interest and dividends (taxable and nontaxable) from Federal Form 1040 or 1040-SR, lines 2a, 2b and 3b......... 15 16 Taxable refunds, credits or offsets of state and local income taxes from Federal Form 1040 or 1040-SR, Sch 1, line 1....................................................................................................................................................... 16 17 Alimony received from Federal Form 1040 or 1040-SR, Schedule 1, line 2a.............................................. 17 Business income (or loss) from Federal Form 1040 or 1040-SR, Schedule 1, line 3.................................. 18 18 29 Cash public assistance received. Enter here and on page 1, Part 2, line 1a............................................. 29 30 Other non-taxable income including child support, worker’s compensation and monetary gifts..................................... 30 31 Addback of rental losses, etc. from lines 18, 19, 21, 22 or 25 above.......................................................... 32 31 TOTAL 2021 HOUSEHOLD INCOME. Add lines 28, 29, 30 and 31. Enter here and on page 1, line 1b....... 32 Enter the income amounts from your 2021 federal 1040 on the appropriate lines below. If you did not file a federal 1040, enter your income amounts on the appropriate lines below. Revised 12/2021 State of Rhode Island Division of Taxation 2021 Form RI-1040H Rhode Island Property Tax Relief Claim Your name Your social security number Your name Your social security number May the Division of Taxation contact your preparer? YES Your signature Spouse’s signature Date Telephone number Paid preparer address City, town or post office State ZIP code PTIN Paid preparer signature Print name Date Telephone number Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 21100299990102

WHEN AND WHERE TO FILE Form RI-1040H must be filed by April 15, 2022. Since April 15, 2022 falls on a Friday, and Emancipation Day, a Washington DC holi- day is being observed on this day, Rhode Island income tax returns will be consid- ered timely filed if post-marked by Monday, April 18, 2022.

Even if you are seeking a filing extension for your Rhode Island income tax return, RI- 1040, Form RI-1040H must be filed by April 15, 2022. An extension of time to file Form RI-1040, does NOT extend the time to file Form RI-1040H.

If filing with Form RI-1040, your property tax relief credit will decrease any income tax due or increase any income tax refund.

If you are not required to file a Rhode Island income tax return, Form RI-1040H may be filed by itself without attaching it to a Rhode Island income tax return. However, Form RI-1040H must be filed by April 15, 2022.

Your property tax relief claim should be filed as soon as possible after December 31, 2021. However, no claim for the year 2021 will be allowed unless such claim is filed by April 15, 2022. For additional filing instructions, see RIGL §44-33. Mail your property tax relief claim to the Rhode Island Division of Taxation - One Capitol Hill - Providence, RI 02908-5806.

Since April 15, 2022 falls on a Friday, and Emancipation Day, a Washington DC holi- day is being observed on this day, Rhode Island income tax returns will be consid- ered timely filed if post-marked by Monday, April 18, 2022.

WHO MAY QUALIFY To qualify for the property tax relief credit you must meet all of the following conditions: a) You must be sixty-five (65) years of age or older and/or disabled. b) You must have been domiciled in Rhode Island for the entire calendar year 2021. c) Your household income must have been $30,000.00 or less. d) You must have lived in a household or rented a dwelling that was subject to property taxes. e) You must be current on property tax and rent payments due on your homestead for all prior years and on any current installments.

WHO MAY CLAIM CREDIT If you meet all of the qualifications outlined above, you should complete Form RI-1040H to determine if you are entitled to a credit.

Only one person of a household may claim the credit. If there are multiple individuals within a household, the taxable and non-taxable income of all household members must be included in part 5 of this return. If the household income of all members is less than or equal to the $30,000 threshold, the credit may still be claimed, but only by one member of the household.

The right to file a claim does not survive a person's death; therefore a claim filed on behalf of a deceased person cannot be allowed. If the claimant dies after having filed a timely claim, the amount thereof will be disbursed to another member of the house- hold as determined by the Tax Administrator.

ATTACHMENTS - Keep your originals - send in copies Attached to this claim shall be: For homeowners: A copy of your 2021 property tax bill. For renters: Copies of three (3) rent receipts for the year 2021, or a copy of your 2021 lease agreement. You should keep your original rent receipts and send in photo- copies printed on letter sized (8 1/2” x 11”) paper. If you lived in subsidized housing, attach a copy of your HUD statement.

If you are a claimant under age 65, you MUST attach a copy of your social secu- rity disability award letter or Form 1099-SSA for the year 2021. IMPORTANT DEFINITIONS What is meant by "disabled" - The term "disabled" means you are receiving a social security disability benefit.

What is meant by "homestead" - The term "homestead" means your Rhode Island dwelling, whether owned or rented, and so much of the land around it as is reason- ably necessary for the use of the dwelling as a home, but not exceeding one acre. It may consist of a part of a multi-dwelling, a multi-purpose building or another shel- ter in which people live. It may be an apartment, a houseboat, a mobile home or a farm.

What is meant by a "household" - The term "household" means one or more persons occupying a dwelling unit and living as a single nonprofit housekeeping unit. House- hold does not mean bona fide lessees, tenants or roomers and borders on contract.

What is meant by a “dependent” - The term “dependent” means any person living in the household who is under the age of 18 who can be claimed by someone else on their tax return.

What is meant by "household income" - The term "household income" means all income received both taxable and nontaxable by all persons of a household in a calendar year while members of the household.

What is meant by "rent paid for occupancy only" - The term "rent paid for occupancy only" means the gross rent paid only for the right of occupying your homestead. If you rented furnished quarters, or if utilities were furnished, such as heat, electricity, etc., then you must reduce the amount of gross rent by the reasonable rental value (not cost) of the furniture and the reasonable value of such utilities as were fur- nished.

What is meant by “public assistance” - The term “public assistance” means cash as- sistance from government assistance programs informally known as welfare assis- tance, and more commonly known as “Temporary Assistance for Needy Families (TANF)”. Under RIGL 44-33-16, a claim for property tax relief shall exclude all taxes or rent paid with public assistance.

Note: Part 5, line 29 and Part 2, line 1a must be equal.

LIMITATIONS ON CREDIT Under the provisions of RIGL 44-33-16, a claim for relief shall exclude all taxes or rent paid with public assistance funds. The maximum amount of credit allowable under Chapter 44-33, Property Tax Relief Act, for calendar year 2021 is $415.00. In the event that more than one person owns the residence, the taxes will be divided by the owner's share.

RENTED LAND If you live on land that is rented and your home or trailer is subject to property tax. Mul- tiply the amount of rent you paid in 2021 by 20% and add the amount to the property tax paid. Then enter the total on RI-1040H, line 2.

Example:

Rent ($3,600 X 20%)........................ ___________

Property Tax...................................... ___________

Amount to be entered on line 2......... ___________ GENERAL INSTRUCTIONS COMPUTATION TABLE INSTRUCTIONS Read down the column titled household income until you find the income range that includes the amount shown on line 32. Read across from the income range line determined in step 1 to find the percent of income allowed as a credit. Enter this percentage on line 3 or line 9, whichever applies. Percentage of income allowable as credit Household income 1 person 3% 4% 5% 6% 6% 2 or more 3% 4% 5% 5% 6%

Less than 6,001 6,001 - 9,000 9,001 - 12,000 12,001 - 15,000 15,001 - 30,000 Step 1 Step 2 State of Rhode Island Division of Taxation 2021 Form RI-1040H Rhode Island Property Tax Relief Claim