District of Columbia Corporation Franchise Tax Return

Corporation Franchise Tax Return
Form D-20
Print

Clear
Government of the
District of Columbia

2024 D-20 Corporation
Franchise Tax Return

Important: Print in CAPITAL letters using black ink.
Taxpayer Identification Number (TIN)

Number of business locations
In DC:

*240200110002*
Tax period ending (MMDDYYYY)

OFFICIAL USE ONLY

Vendor ID# 0002

Outside DC:

Name of corporation

Business mailing address #1

Fill in

if Amended Return

Fill in

if Final Return

Fill in

if 52-53 week filer

Fill in

Fill in
Fill in

Business mailing address #2

Fill in

City

State

GROSS INCOME

if QHTC located in DC Ballpark
TIF Area

Enter dollar amounts only.
If amount is zero, leave line blank; if minus, enter amount and fill in oval.

(To allocate non-business Items, see instructions)

2

$
$

..00
..00

3

$

..00

$
5 $
6 $
7 $
8(a)$
8(b)$
9 $

..00
..00
..00
..00
..00
..00
..00

$
$
$
$
$
$
$
$

..00
..00
..00
..00
..00
..00
..00
..00

.00 = 18c $

..00
..00
..00

Gross receipts, minus returns and allowances

1

2

Cost of goods sold (from D-20 Schedule A) and/or operations
(attach statement)

Gross profit from sales and/or operations

Fill in if minus:

Line 1 minus Line 2

4

Dividends from Form D-20, Schedule B

5

Interest (attach statement)

6

Gross rental income from D-20, Schedule I, Column 3, Line 6

7

Gross royalties (attach statement)

4

8(a) Net capital gain (loss) (attach a copy of your federal Schedule D)

Fill in if minus:

(b) Ordinary gain (loss) from Part II, fed. Form 4797, (attach copy)

Fill in if minus:

9

Capital gains deferred on federal return due to investment in a federal
Qualified Opportunity Fund
Fill in if minus:
10 Other income (loss) (attach statement)

11 Total gross income. Add Lines 3-10.

DEDUCTIONS

if Certified QHTC

Designated Agent TIN

1

3

if Worldwide**

**Worldwide form must be filed with
this return

Zip Code + 4

Designated Agent Name

•READ INSTRUCTIONS BEFORE PREPARING RETURN•

if Combined Report*

*You must fill in the Designated Agent
info below

10
11

Fill in if minus:

12 Compensation of officers from Form D-20, Schedule C

12

13 Salaries and wages

13

14 Repairs

14

15 Bad debts

15

16 Rent

16

17 Taxes from Form D-20, Schedule D

17

18(a) Interest payments

$

(b) Minus nondeductible payments to related entities $

.00

19 Contributions and/or gifts (attach statement)

19

20 Amortization (attach a copy of your federal Form 4562)

20

$
$

21 Depreciation (attach a copy of your federal Form 4562. Do not include

21

$

..00

22 Depletion (attach statement)

22

$

..00

.00 = 23c $

..00

any additional IRC 179 expenses or IRC 168(k) depreciation)

23a) Enter royalty payments made

$

(b) Minus nondeductible payments to related entities $
Revised O9/2024

.00

D-20 FORM, PAGE 2

*240200120002*
$
$

.00
.00

28

28

$
$
$

.00
.00
.00

29

29a $

.00
.00
.00
.00

24

24

25

25

26

26

27 Total deductions. Add lines 12-26.

27

29b$
29c $
30

30

31

$

31

3,

.

.00

32

32

$

33

33

$

.00

34

34

$

.00

35

$

.00

36

$
$
$

.00
.00
.00

35
*(Losses occurring in tax year 2018 or later are limited to 80%. See instructions.)

36 Total DC taxable income.

Line 34 minus Line 35.

37 Tax: 8.25% of Line 36.

37

38

38

.00

$

39
40

4

41

$

41a $
41b$

41c $

2024
42

41d$
42 $

2024

43
44

43

45

45

46
47

46

44

2025

48

47
48

To authorize another person to discuss this return with OTR, fill in here

PLEASE
SIGN
HERE

PAID
PREPARER
ONLY

Revised 09/2024

$
$
$
$
$
$

.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00

and enter the name and phone number of that person. See instructions.

D-20 FORM, PAGE 3

*240200130002*

Taxpayer Name:
Taxpayer Identification Number:

Schedule A - Cost of Goods Sold (See specific instructions for Line 2.)

Schedule B - Dividends (See specific instructions for Line 4.)
AMOUNT

NAME AND ADDRESS OF DECLARING CORPORATION

1. Inventory at beginning of year............................... $

$

2. Merchandise bought for manufacture or sale..........
3. Salaries and wages.............................................
4. Other costs per books (attach statement)...............
(Additional federal depreciation and additional IRC § 179
expenses are not allowable.)

5. Total ................................................................

$

6. Minus: Inventory at end of tax year......................
7. Cost of goods sold (Enter here and on D-20 Line 2.)

$

Method of inventory valuation:
Total Dividends
$

Minus deduction for Subpart F Income.
Minus deduction for dividends received from
wholly-owned subsidary

$

TOTAL (Enter here and on D-20, Line 4.)

Schedule C - Compensation of officers (See specific instructions for Line 12. If more than 3 officers attach additional sheets as needed.)
Col. 1
Name and Address of Officer

Col. 2
Official Title

Percent of Corporation
Stock Owned

Col. 3
Percent of Time
Devoted to
Business

Col.5
Preferred

Col. 4
Common

Col. 7
Expense
Account
Allowances

Col. 6
Amount
of
Compensation

%

%

%

%

%

%

%

%

%

TOTAL COMPENSATION OF OFFICERS (Enter here and on D-20, Line 12.)

$

$

$

Schedule D - Taxes (See specific instructions for Line 17.)
AMOUNT

EXPLANATION

AMOUNT

EXPLANATION

$

$

TOTAL (Enter here and on D-20, Line 17.)

$

Schedule E - Reconciliation of the net income reported on Federal and DC returns
1. Taxable income before net operating loss deduction and special
deductions (page 1 of your Federal corporate return).

$

7. Total DC taxable income reported (from D-20, Line 36. $

UNALLOWABLE DEDUCTIONS AND ADDITIONAL INCOME
2. Income taxes (see specific instructions for Line 17).

NON-TAXABLE INCOME AND ADDITIONAL DEDUCTIONS

3. DC income taxes and franchise taxes imposed by DC Revenue
Act of 1947, as amended.

8. Net income apportioned or allocated to outside DC.

4. Interest on obligations of states, territories of the U.S. or
any Political Subdivision thereof.

9. Other non-taxable income and additional deductions
including NOL (itemize):

5. Other unallowable deductions and additional income (itemize,
include additional federal depreciation and additional
IRC § 179 expenses).

(a) _____________________________________________________

(a) ______________________________________________________

(b) _____________________________________________________

(b) ______________________________________________________

6. TOTAL of Lines 1–5.

Revised 09/2024

$

10. TOTAL of Lines 7, 8 and 9.

$

D-20 FORM, PAGE 4

*240200140002*

Taxpayer Name:
Taxpayer Identification Number:

Schedule F - DC apportionment factor (See instructions) Note: If this is a combined report do not use Schedule F to derive the apportionment factor for the group.
Leave Schedule F blank. Use Combined Reporting Schedule 2A, Line 9 instead.
Round cents to the nearest dollar.

Carry all factors to six decimal places and truncate.

Column 1: TOTAL

For all businesses other than financial institutions:
1. SALES FACTOR: All gross receipts of the business other
than gross receipts from non-business income.

Column 2: in DC

$

.00

2. SALES FACTOR: All gross income of the financial institution other
than gross income from non-business income.

$

.00

3. PAYROLL FACTOR: Total compensation paid or accrued by the
financial institution.

$

.00

Column 3: Factor

(Column 2 divided by Column 1)

.00

.

$

.00

.

$

.00

.

$

For Financial Institutions:

4. SUM OF FACTORS: (For Financial Institutions add Lines 2 and 3 of Column 3)

.

5. DC APPORTIONMENT FACTOR: For businesses other than financial institutions enter the number from Line 1, Column 3. Enter on D-20,
Line 31. For financial institutions divide Line 4, Column 3 by 2. Enter on D-20, Line 31.

.

Schedule G - Balance Sheets

Beginning of Taxable Year
(A) Amount
(B) Total

End of Taxable Year
(A) Amount
(B) Total

1. Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Trade notes and accounts receivable. . . . . . . . . . . . . .
(a) MINUS: Allowance for bad debts. . . . . . . . . . . . . .
3. Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Gov’t obligations:

(a) U.S. and its instrumentalities. . . .

ASSETS

(b) States, subdivisions thereof, etc. .
5. Other current assets (attach statement). . . . . . . . . . . .
6. Loans to stockholders. . . . . . . . . . . . . . . . . . . . . . . . .
7. Mortgage and real estate loans. . . . . . . . . . . . . . . . . . . .
8. Other investments (attach statement). . . . . . . . . . . . . .
9. Buildings and other fixed depreciable assets . . . . . . . .
(a) MINUS: Accumulated depreciation. . . . . . . . . . . . .
10. Depletable assets. . . . . . . . . . . . . . . . . . . . . . . . . . . .
(a) MINUS: Accumulated depletion. . . . . . . . . . . . . . . .
11. Land (net of any amortization). . . . . . . . . . . . . . . . . .
12. Intangible assets (amortizable only) . . . . . . . . . . . . . .
(a) MINUS: Accumulated amortization . . . . . . . . . . . .
13. Other assets (attach statement) . . . . . . . . . . . . . . . . .
14.

TOTAL ASSETS . . . . . . . . . . . . . . . . . . . . . . . . .

LIABILITIES AND CAPITAL

15. Accounts payable . . . . . . . . . . . . . . . . . . . . . . . . . . .
16. Mortgages, notes, bonds payable in less than 1 year.
17. Other current liabilities (attach statement). . . . . . . . . .
18. Loans from stockholders . . . . . . . . . . . . . . . . . . . . . .
19. Mortgages, notes, bonds payable in 1 year or more . .
20. Other liabilities (attach statement) . . . . . . . . . . . . . . .
21. Capital stock:

(a) Preferred stock . . . . . . . . . . . . . .
(b) Common stock . . . . . . . . . . . . . .

22. Paid-in or capital surplus (attach statement) . . . . . . . .
23. Retained earnings - Appropriated (attach statement) . .
24. Retained earnings - Unappropriated . . . . . . . . . . . . . .
25. MINUS: Cost of treasury stock . . . . . . . . . . . . . . . . . .
26.

TOTAL LIABILITIES AND CAPITAL . . . . . . . . . .

Revised 09/2024

(

)

(

)

D-20 FORM, PAGE 5

*240200150002*

Taxpayer Name:
Taxpayer Identification Number:

Schedule H-1 – Reconciliation of Income (Loss) per Books With Income (Loss) per Return
1. Net income per books. . . . . . . . . . . . . . . . . . . . $

7. Income recorded on books this year and not
included in this return (itemize).
Tax-exempt interest $______________

2. Federal income tax . . . . . . . . . . . . . . . . . .

$

3. Excess of capital losses over capital gains . .
4. Taxable income not recorded on books this
year (itemize) . . . . . . . . . . . . . . . . . . .
8. Deductions on this tax return and not charged
against book income this year (itemize).

5. Expenses recorded on books this year and not
deducted on this return (itemize).

(a) Depreciation . . . . . $ ______________

(a) Depreciation . . . . . . $_______________

(b) Depletion . . . . . . . . $ ______________

(b) Depletion . . . . . . . $_______________

9. TOTAL of Lines 7 and 8 . . . . . . . . . . . . . . . . $
10. Taxable Income (federal Form 1120, page 1, line 28
should equal Line 6 minus Line 9 of this Schedule.) $

6. TOTAL of Lines 1 through 5. . . . . . . . . . . . . . .

$

Schedule H-2 – Analysis of Unappropriated Retained Earnings per Books
1. Balance at beginning of year . . . . . . . . . . . .

5. Distributions:

$

2. Net income per books . . . . . . . . . . . . . . . . .
3. Other increases (itemize) . . . . . . . . . . . . . . .

(a) Cash . . . . .. . . . . . . . . .
(b) Stock . . . . . . . . . . . . . .
(c) Property . .. . . . . . . . . .

$

6. Other decreases (itemize).

4. TOTAL of Lines 1, 2 and 3.

$

7. TOTAL of Lines 5 and 6. . . . . . . . . . . . . . . .

$

8. Balance at end of year (Line 4 minus Line 7). .

$

Schedule I – Income from Rent
Col. 1:
Address of Property

Col. 2:
Kind of Property

Col. 3: Gross
Amount of Rent

Col. 4: Depreciation*
or Amortization (Per
Federal Form 4562)

Col. 5: Repairs
Explain in Sch. I-1

Col. 6: Taxes, Interest
and other Expenses*
(Explain in Sch. I-1)

$
$
$
$
1. ______________________________________________________________________________________________________________________________
_____

2. ___________________________________________________________________________________________________________________________________
3. ___________________________________________________________________________________________________________________________________
4. ___________________________________________________________________________________________________________________________________
5. ___________________________________________________________________________________________________________________________________
6. TOTAL (Enter the total of Column 3 on D-20, Line 6. $
Enter total of Column 4, 5, and 6 on appropriate deduction lines.)

$

$

$

*excludes federal depreciation and additional IRC §179 expenses.
Schedule I-1 – Explanation of deductions claimed in Columns 5 and 6 of Schedule I.
Column
Column
No.
Explanation
Amount
No.
Explanation
Amount
______________________________________________________________________________________________________________________________________

$
$
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Revised 09/2024

D-20 FORM, PAGE 6

*240200160002*

Taxpayer Name:
Taxpayer Identification Number:

*
Schedule K- Disregarded Entities (Name and TIN for any single member limited liability company that is treated as a disregarded entity for District franchise tax
purposes, whose income is included in the income reported on this return, and which is doing business in the District). (See instructions.)
Disregarded Entity Name

TIN

Supplemental Information
1.

STATE OR COUNTRY OF INCORPORATION

4.

THE CORPORATION’S BOOKS ARE IN THE CARE OF –

6.

2.(a)

DATE OF INCORPORATION

2.(b)

5.

DATE BUSINESS BEGAN IN DC

3. IRS SERVICE CENTER WHERE FEDERAL RETURN

WAS FILED FOR PERIOD COVERED BY THIS RETURN:

LOCATED AT –

During 2024, has the Internal Revenue Service made or proposed any
adjustments to your federal income tax return, or did you file any amended
returns with the IRS? YES
NO

If you have already provided OTR with

a detailed statement, enter the date
it was sent.

If “YES,” please submit separately a detailed statement, unless previously
submitted, to the address shown in the instructions under Amended Returns.
7. Is this corporation unitary with another entity?

YES

NO

If yes, explain:

8. Is this return made on the accrual basis?

YES

NO

If no,, indicate basis used:
us

9. Did you file a franchise tax return with DC
for the year 2023?

YES

NO

If no, state reason

10. Did you withhold DC income tax from wages paid to your
DC resident employees during 2024?

YES

NO

If no, state reason:

11. Did you file annual information returns, federal forms 1096
and 1099, relating to payment of dividends and interest for
2024?

YES

NO

12. (a) Has the business been terminated?

YES

NO

YES

NO

YES

NO

(b) Have you moved out of DC?
13. Did you file an annual ballpark fee return?

*Schedule J has been deleted.

Revised 09/2024

If yes, explain and give date:

Cash Basis

MM/DD/YYYY

Other (specify)

Print

Clear

Government of the
District of Columbia

Worldwide Combined Reporting
Election Form

Taxpayer Identification Number of Designated Agent			

*242300110002*

Taxable Year YYYY		

Name of Designated Agent				

Worldwide
Telephone number

Business address line #1

Business address line #2		

City	

State	

Zip code +4

•

In accordance with the provisions of DC Official Code § 47-1810.07 and the combined reporting regulations, election is
hereby made to report on a worldwide unitary combined basis.

•

A worldwide unitary combined reporting election is binding for and applicable to the tax year it is made and all years
thereafter for a period of ten years.

•

It may be withdrawn or reinstituted after withdrawal, prior to the expiration of the ten-year period, only upon written
request for reasonable cause based on extraordinary hardship due to unforeseen changes in DC tax statutes, law or
policy and only with the written permission from the DC Office of Tax and Revenue.

•

Upon the expiration of the ten-year period, a taxpayer may withdraw from the worldwide unitary combined reporting
election.

•

Withdrawal must be made in writing within one year of the expiration of the election and is binding for a period of ten
years, subject to the same conditions as applied to the original election.

Date Beginning Tax Period: MMDDYYYY			

Date Ending Tax Period: MMDDYYYY

Authorized Signature

Printed Name				

Date

Under penalties of law, I declare that the designated agent has authorized me to sign on behalf of all members of the combined group, and that I have examined
this form and the information contained herein is, to the best of my knowledge and belief, correct and complete.

Revised 04/2024

Print

Clear
Government of the
District of Columbia

*242300310002*

2024

Important: Print in CAPITAL letters using black ink.

NOTE: READ INSTRUCTIONS BEFORE
COMPLETING THIS FORM

Worldwide
of Designated Agent

YY

Taxable year ending MM

Number of members in the combined group

Name of Designated Agent

Telephone number

Business mailing address line #1

Business mailing address line #2
City

State

A

List the designated agent and all
combined members

B
Identification Number

C

Was a separate
DC franchise tax
return filed in the
prior year?

Zip Code + 4

D

Is the member new
to the
combined group?

E

Was gross income
received from
District sources?

F

Does the member
have nexus in DC?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Note: If more than 1 combined members, continue list on a separate sheet of paper.
Revised 04/2024

Print

Clear

Government of the
District of Columbia

2024 SCHEDULE UB
Business Credits

Important: Print in CAPITAL letters using black ink.
Attach to your Form D-20 or D-30.
Taxpayer Identification Number

*242300210002*
OFFICIAL USE ONLY

Vendor ID# 0002

Fill in

if FEIN

Fill in

if filing a D-20 Return

Fill in

if SSN

Fill in

if filing a D-30 Return

Enter your business name

D-20 Return
Nonrefundable Credits (Nonrefundable Credits may not be applied against the required minimum tax)
1

Economic Development Zone Incentives Credits (see worksheet).

1

$

2

Qualified High Technology Company Credits from Part D, Line 4a, DC Form D-20CR.

2

3

Organ and Bone Marrow Donor Credit (see computation on reverse side).

3

4

Job Growth Incentive Act

4

$
$
$

.00
.00
.00
.00

5

Enter alternative fuel credits. See instructions
5a Alternative fuel infrastructure.

9

$
$
$
$
$

.00
.00
.00
.00
.00

10

$

.00

$
12 $

.00
.00

$

14

5b Alternative fuel vehicle conversion.

6
7

$

.00

$

.00

# of stations
# of vehicles

Add Lines 5a and 5b only and enter here.

5

DHCD Rental Accommodations Division Housing Provider Credit (see instructions)

6

Employer-assisted Home Purchase Tax Credit (see computation on reverse side). 7a
7
# of employees
8

8

DC Low-Income Housing Tax Credit (see instructions).

9

Total the nonrefundable D-20 credits (Lines 1-8), enter here and on Form D-20, Line 38.

Refundable Credits
10

RESERVED

11

11

12 Total the refundable D-20 credits, enter here and on Form D-20, Line 41 d .

D-30 Return
Nonrefundable Credits (Nonrefundable Credits may not be applied against the required minimum tax)
13 Economic Development Zone Incentives Credit (see worksheet).

13

14 Organ and Bone Marrow Donor Credit

$
15 $

.00
.00
.00

$
17 $
18 $
19 $
20 $

.00
.00
.00
.00
.00

(see computation on reverse side)

15 Job Growth Incentive Act
16 Enter alternative fuel credits. See instructions
16a Alternative fuel infrastructure.
16b Alternative fuel vehicle conversion.

$

.00

$

.00

# of stations
# of vehicles

Add Lines 16a and 16b only and enter here.
17 DHCD Rental Accommodations Division Housing Provider Credit (see instructions)
18 Employer-assisted Home Purchase Tax Credit (see computation on reverse side). 18a
# of employees
19 DC Low-Income Housing Tax Credit (see instructions).
20 Total the nonrefundable D-30 credits (Lines 13-19), enter here and on Form D-30, Line 38.

Refundable Credits

16

1

1

$

.00

2 otal the refundable D- 0 credits, enter here and on Form D- 0, Line 41(d).

2

$

.00

Revised 08/2024

Schedule UB Instructions - Qualified High Technology Companies

If you claim credits on Line 2 above, attach a copy of your DC Form D-20CR to the D-20.

Organ and Bone Marrow Donor Credit
An employer who provides an employee with paid leave to donate an organ (up to 30 days
leave) or to donate bone marrow (up to 7 days leave) is eligible to claim a credit against the
franchise tax. The credit is equal to 25% of the salary paid to the employee during the leave
period. If you take the credit, you may not also take a deduction for the salary paid to the
donor employee for that period. This credit is not available if the employee is eligible for leave
under the Family and Medical Leave Act of 1993.

Organ and Bone Marrow Donor Credit
— Computation —

Column 1
Credit Category

Column 2
Total Paid Leave

Column 3
Leave Credit Calculation

Organ Donor(s)

Total Paid Leave
Wages

Col 2 ______________
amt.

$_______________

x 25% ____________
$__________________

Bone Marrow
Donor(s)

Total Paid Leave
Wages

Col 2 ______________
amt.

$_______________

x 25% ____________

Column 4
Total Credit

$________________

$__________________

$________________

Total of Col. 4.
Enter here and
on Schedule UB.*

$0
$________________

*Line 3 of Schedule UB for D-20 filers
Line 14 of Schedule UB for D-30 filers

Employer-Assisted Home Purchase Tax Credit
— Computation —
1. Number of Eligible Employees
2. Amount of Homeownership Assistance provided
during this period to Eligible Employees ...........................x 50%
3. Tax Credit ..............................................................................
(Cannot exceed Line 2 amount and limited to $2,500 per Eligible
Employee)

$
$

Enter amount from Line 3 on
Line 7 of Schedule UB for D-20 filers, or
Line 18 of Schedule UB for D-30 filers.
Employer-Assisted Home Purchase Tax Credit
An employer who provides homeownership assistance to eligible employees
through a certified home purchase program may be eligible to claim a credit
against the franchise tax if certain conditions are met. See instructions and
DC Code Section 47-1807.07 for further details.

Print Form

Clear Form

Government of the
District of Columbia

2024 SCHEDULE

Property Tax

Important: Read eligibility requirements before completing.
Print in CAPITAL letters using black ink.

Credit

*24SR00110002*
OFFICIAL USE ONLY

Taxpayer Identification Number

Fill in
Fill in

if FEIN
if SSN

Fill in

if filing a D-20 Return

Fill in

if filing a D-30 Return

Vendor ID#0002

Sales and Use Tax Account Number

Enter your business name

Mailing address (number, street and suite number if applicable)

City

State

Address of

Zip Code +4

DC roperty (number, street and suite number if applicable) for which you are claiming the credit (if different from above)

State

City

Zip Code +4

Certificate of Occupancy Permit Number
If member of a Combined Group, Taxpayer Identification Number of Designated Agent

Do not claim this credit if your qualified business is exempt from or receives any tax credits towards its real
property tax, or if the qualified rental retail location or the qualified owned retail location is otherwise exempt from
real property tax.
The credit equals the total Class 2 real property taxes paid by a qualified corporation or qualified unincorporated
business for a qualified retail owned location during the taxable year not to exceed $10,000; or 10% of the total
rent paid by a qualified corporation or qualified unincorporated business for a qualified rental retail location not to
exceed $10,000.

Do not make claim if $3m or more.

1

.00

$

.00

2024
2024
2024

.00
1 0 0 0 0 .00
.00

Landlord’s name
Landlord’s address (number and street)

elephone number
City

State

Zip Code +4

If Owner, enter information from your real property tax bill or assessment. If a section is blank on your property tax bill, leave it blank here.

Square number
Revised 06/2024

Suffix number

Lot number