Dor Form 82514 - Affidavit Of Individual Tax Exemption
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AFFIDAVIT OF INDIVIDUAL TAX EXEMPTION
SEE REVERSE FOR INSTRUCTIONS
TYPE
COUNTY
FILE
PART II. DISABLED (Totally and Permanently)
Spouse’s Name ______________________________________________
NAME:
____________________________________________
Date of Medical Certificate _____________
_
ADDRESS: ____________________________________________
1. None of my children under 18 years of age resided with me during the previous
calendar year. The total income from all sources of myself, my spouse, and
____________________________________________
any of my children 18 years of age or more who resided with me did not
exceed $30,536 during the previous calendar year.
PHONE:
_________________________
2. At least one of my children, who is under 18 years of age or who was totally
and permanently disabled, resided with me during the previous calendar
year. The total income from all sources of myself, my spouse, and any
other of my children residing with me did not exceed $36,643 during
the previous calendar year.
PART III. ALL APPLICANTS MUST COMPLETE
1. Are you now a legal resident of this state?
Yes
No
2. When did you first become a resident of this state? ________________
PART I. WIDOWS AND WIDOWERS
3. Where in the state did you first establish residence?
1. None of my children under 18 years of age resided with me during the
City/Town _______________________ County ____________________
previous calendar year. The total income from all sources of myself, my
spouse, and any of my children 18 years of age or more who resided
4. Do you own property in this county?
Yes
No
with me did not exceed $30,536 during the previous calendar year.
5. Do you own property in another Arizona County?
Yes
No
2. At least one of my children, who is under 18 years of age or who was totally and
permanently disabled, resided with me during the previous calendar year.
If yes, in which county: _____________________________________
The total income from all sources of myself, my spouse and any other of my
children residing with me did not exceed $36,643 during the previous calendar
6. Is part of the property you own an Arizona business? Yes
No
year.
If yes, provide Business Name and Address: _______________________
Spouse’s Name _____________________________________________
___________________________________________________________
Date of Death _______________ Have you remarried? Yes
No
___________________________________________________________
City and State of Death ____________________________________________
7. Are you claiming your exemptions in any other county? Yes
No
Death Certificate Number_______________ Recording Date _______________
If yes, in which county? ________________________________________
Were you divorced from the deceased at the time of death? Yes
No
CODE
SEQ.
PROPERTY LIST
INT %
ASS’D %
FULL CASH
ASSESSED
EXEMPT
LIMITED
ASSESSED
EXEMPT
VALUE
VALUE
AMOUNT
VALUE
VALUE
AMOUNT
X
I HEREBY CERTIFY THAT I HAVE READ ALL OF THE FOREGOING BEFORE
____________________________________________________________________
PROPERTY OWNER
DATE
SUBSCRIBING MY NAME HERETO, THAT THE MATTERS HEREIN STATED ARE
ALL TRUE TO THE BEST OF MY KNOWLEDGE, AND THAT MY PROPERTY’S
TOTAL ASSESSED VALUE IN ARIZONA DOES NOT EXCEED $24,900.
X
____________________________________________________________________
DEPUTY ASSESSOR/NOTARY
DATE MY COMMISSION EXPIRES
DOR FORM 82514 (Rev. 12/2013)
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