Claim For Home Exemption
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1
2Parcel ID (Tax Map Key)
REAL PROPERTY ASSESSMENT DIVISION
DEPARTMENT OF BUDGET
AND FISCAL SERVICES
CITY AND COUNTY OF HONOLULU
Above enter 12-digit parcel ID
Please include: -HEX at end of numbers
For example: 210630150000-HEX
CLAIM FOR HOME EXEMPTION
Sections 8-10.4 and 8-10.5, ROH
Please read instructions on the back before completing this form
PRINT OWNER/OCCUPANT’S NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SIGNATURE (See certification below)
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
PRINT OWNER/OCCUPANT’S NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SIGNATURE (See certification below)
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
PROPERTY (PARCEL) ADDRESS
APT
CITY
STATE
ZIP
MAILING ADDRESS IF DIFFERENT FROM PROPERTY ADDRESS
APT
CITY
STATE
Zip
How many living units are located on this parcel?
________ living units
)
(For purposes of this exemption claim, your co-op unit or condominium unit counts as one living unit
How many owners reside on this parcel?
________ owners
How many owners living in this unit?
________ owners
Is any portion of this parcel or living unit being used as a rental or for business purposes?
No
Yes
If “Yes,” indicate the building area (square feet) used for rental or business purposes:
____________ square feet
I am a legal resident of: ________________________
______________________
______________________
Country
State
County
Do you have a home exemption anywhere else?
No
Yes
If “Yes,” list the Tax Map Key and/or address of the parcel: ______________________________________________
For proof of filing the home exemption, do one of the following:
1. Deliver to RPAD, 842 Bethel Street, Basement Honolulu, HI 96813; or RPAD, 1000 Uluohia St #206 Kapolei HI, 96707 or any Satellite City Hall
requesting a receipted copy.
2. Mail to RPAD, 842 Bethel Street, Basement Honolulu, HI 96813; or RPAD, 1000 Uluohia St #206 Kapolei HI, 96707 and include a self-addressed
stamped envelope to receive a receipted copy.
3. Mail via Certified or Registered Mail to RPAD, 842 Bethel Street, Basement Honolulu, HI 96813; or RPAD, 1000 Uluohia St #206 Kapolei HI, 96707
CERTIFICATION
I (we) certify that I own and occupy this home in accordance with Section 8-10.4, ROH, and that the foregoing is true and
correct to the best of my knowledge. I understand that any misstatement of facts will be grounds for disqualification. I also
understand if I cease to qualify for such exemption, I must report to the assessor within 30 days this change in facts or status.
Failure to report a change in facts or status will result in disqualification and penalties.
FOR OFFICIAL USE ONLY
Received By: ______________________________________________
Tenancy #: ___________
Building Exemption %: ________________
Date Received (post office cancellation mark): ______________________________
Building #: ___________
Land Exemption %: ________________
For Tax Year: _____________________________________________
Building #: ___________
BFS-RP-P-3 (Rev 08/14)
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