Iowa Special Assessment Property Tax Credit Claim (with instructions)

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2026 Iowa Special Assessment Property Tax Credit Claim Iowa Code section 425.23(3) and Iowa Administrative Code rule 701-104.27 Complete the following personal information: Your name: ______________________________ Your Social Security Number: ________________ Your birth date (MM/DD/YYYY): ______________ Spouse name: ______________________________ Spouse Social Security Number: _______________ Spouse birth date (MM/DD/YYYY): ______________ Address: _________________________________ City: ______________________________________ State: ________________ ZIP: _______________ Phone: ____________________________________ Were you age 65 or older, or totally disabled and age 18 or older, as of December 31, 2025? ................................................................................................................... Yes ☐ No ☐ If "No," stop. No credit is allowed. If you are under age 65 and totally disabled, you must include proof of disability . Provide proof of disability such as a current statement from Social Security Administration, Veterans Administration, your doctor, or Form SSA-1099. 2025 Total household income for the entire year Read instructions before completing

Use whole dollars only 1. Iowa taxable income (see instructions) If less than zero, enter 0 ......................... 2. In-kind assistance for housing expenses ............................................................. 3. Title 19 benefits (excluding medical benefits) ...................................................... 4. Social Security income ......................................................................................... 5. Disability income and workers' compensation ...................................................... 6. All retirement income ........................................................................................... 7. Interest income from federal, state, or local government ..................................... 8. Capital gains and income from a farm tenancy agreement If less than zero, enter 0 ...................................................................................... 9. Money received from others living with you ......................................................... 10. Other income ....................................................................................................... 11. Add amounts from lines 1 through 10 .................................................................. 12. Medical and care expenses (totally disabled individuals only) ............................. 13. Total household income (Subtract line 12 from line 11) ....................................... (If line 13 is more than $13,855 stop. No credit is allowed.) I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this claim, and, to the best of my knowledge and belief, it is true, correct, and complete. Signature: ___________________________________________________ Date: _____________________ This claim must be filed or mailed to your county treasurer on or before September 30, 2026. , .00 , .00 , .00 , .00 , .00 , .00 , .00

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2026 Iowa Special Assessment Property Tax Credit Claim Instructions

Who is eligible? Total household income was not more than $13,855 and: • Age 65 or older by December 31, 2025, or • Totally disabled and age 18 or older by December 31, 2025. Household income includes you r income and your spouse's income, if living together, and monetary contributions received from other persons living with you. If you and your spouse are not living together, each may file a separate claim. Line 1: Iowa taxable income - Enter the amount of Iowa taxable income from your state individual income tax return (IA 1040, Step 4. Line 4). Do not include any net operating loss. If you did not file a 2025 IA 1040, use the IA 1040 to calculate the amount on Step 4, line 4 and enter it on this line. If you are unable to use the IA 1040, enter the amount of your wages, salaries, unemployment compensation, tips, bonuses, commissions, dividends, distributions, or any profit from a business that exceeds the applicable standard deduction amount or itemized deductions amount, if you itemize deductions . For information about the standard deduction amount, see IRS Publication 501. If you are below age 65 and not required to file an IA 1040 for the 2025 tax year because you are below the income threshold, enter zero. If you live with your spouse, include their income. If less than zero, enter zero. Lines 2-10: Any amounts entered on these lines shall be amounts not already included in line 1. Line 2: In-kind assistance - Enter any portion of your housing expenses, including utilities , that were paid for you. Do not include Federal Energy Assistance. Line 3: Title 19 benefits - Enter your Title 19 benefits received for housing expenses. Do not include medical benefits.

# Line 4: Social Security income - Enter the total Social

Security benefits received, even if not reportable for income tax purposes. I nclude any Medicare premiums withheld. Do not include child insurance benefits received by a member of your household. Line 5: Disability income and workers' compensation - Enter the total received for disability or workers' compensation, even if not reportable for income tax purposes. Line 6: All retirement income - Enter the total amount received from a governmental or other pension or retirement plan, including defined benefit or defined contribution plans; annuities; individual retirement accounts; plans maintained or contributed to by an employer, or maintained and contributed to by a selfemployed person as an employer; and deferred compensation plans or any earnings attributable to the deferred compensation plan. Include retirement pay for military service , even if not reportable for income tax purposes. Line 7: Interest income from federal, state, or local governments - Enter interest income from federal, state, and local governments. Line 8: Capital gains and income from a farm tenancy agreement - Enter any capital gain received from the sale or exchange of capital assets that is not already included in line 1 . Capital losses are limited to the same amount that you are allowed to report for income tax purposes. Any loss must be offset against gain, and a net loss must be reported as zero. Enter the amount of income from a farm tenancy agreement covering real property that is not already included in line 1. Line 9: Money received from others living with you - Enter money received from others living with you. Do not include goods and services received. Line 10: Other income - Enter total income received from the following sources: • Child support and alimony payments. • Welfare payments. Include Family Investment Program ( FIP), children's Supplemental Security Income ( SSI), and all other welfare program cash payments. Do not include foster grandparents' stipends or non -cash government assistance ( ex: food, clothing, food stamps, medical supplies, etc.). • Insurance income not reported elsewhere. • Gambling, and all other income, not reported elsewhere. Line 12: Medical and care expenses - Enter all medical and necessary care expenses paid during the year which were related to your disability. These are the same as you are allowed to deduct for federal income tax. Do not enter an amount on line 12 unless you are totally disabled and incurred medical or care expenses attributable to your disability. Line 13: Total household income - Subtract line 12 from line 11. If more than $13,855 no credit is allowed. Additional information: The location of your county treasurer can be found at the Iowa Treasurers website: iowatreasurers.org. For information about your Social Security benefits , go to the Social Security Administration website: ssa.gov/myaccount. For use by County Treasurer only Installment number: ____________________________ Annual special assessment payment: ______________ State reimbursement: ___________________________