Form Sdat - Ex 5a - Application For Exemption Blind Persons printable pdf download

STATE OF MARYLAND

RETURN TO:

DEPARTMENT OF ASSESSMENTS AND TAXATION

APPLICATION FOR EXEMPTION BLIND PERSONS

TO BE FILED with the Supervisor of Assessments in the appropriate local office.

This form seeks information for the purpose of a blind exemption on the indicated property. Failure to provide this information will result in denial of your application. However,

some of this information would be considered a "personal record" as defined in State Government Article, §10-624. Consequently, you have the statutory right to inspect your

file and to file a written request to correct or amend any information you believe to be inaccurate or incomplete. Additionally, personal information provided to the State Department

of Assessments and Taxation is not generally available for public review. However, this information is available to officers of the State, county or municipality in their official

capacity and to taxing officials of any State or the federal government, as provided by statute. Additionally, if your property would be used by the State Department of Assessments

and Taxation as a comparable for purposes of establishing the value of another property in a hearing before the Maryland Tax Court, the requested information, or a portion thereof,

may have to be provided to the owner of that other property.

Title to property is in the name(s):

Address of property:

Location and description of property:

Account Number

Baltimore City

Ward

Section

Block

Lot

Counties

District

Map

Block

Parcel

Subdivision

Description

Date Acquired

Deed Reference

Name of Property Owner

I hereby certify that the above described property is my place of residence, that I am legal owner of said property, and that I meet

the requirements of the Maryland Law granting the exemption from property taxation as the attached doctor's certification will indicate.

I declare under the penalties of perjury, pursuant to Section 1-201, Tax Property Article, Annotated Code of Maryland, that this

return (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is

a true, correct and complete return.

Signature of Blind Person:

Date:

Telephone Number:

The following certification must be completed by a licensed medical doctor or optometrist.

This is to certify that the herein named applicant

, a blind person has been examined by

me, and is found to have permanent impairment of both eyes of the following status: central visual acuity of 20/200 or less in the better eye, with

corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent

that the widest diameter of visual field subtends an angular distance no greater than twenty degrees on the better eye.

Signature

Date

Address

Phone

City

State

Zip Code

Effective Date of Blindness

(FOR OFFICE USE ONLY)

COMMENTS:

New Application G