SENIOR CITIZEN & DISABLED
Dept. of Assessments
King County Admin Bldg
IN PROPERTY TAXES
500 Fourth Ave., Room 740
File Application with the King County Assessor
Seattle, WA 98104-2384
or taxes due in
per RCW 84.36
I am applying for a senior citizen or disabled exemption and certify the following (mark appropriate boxes).
I currently own and occupy this property as my principal residence as of December 31, 2016.
OR I have attached a copy of a Trust or recorded Lease for Life / Life Estate indicating my retained ownership.
I own more than one property. Please provide the address and location of all other properties ___________________________
Attach proof of age such as driver’s license.
I am or will be 61 years of age or older on or before December 31, 2016.
I am disabled and unable to work due to my disability. Attach a current physician’s statement attesting to your disability if
under the age of 61 or
attach a copy of your SSI award letter.
I am a compensated Veteran with a VA determined, 100% service-connected disability.
Attach your VA award letter.
My spouse / domestic partner had an exemption, and I was at least 57 years old in the year he/she passed away.
Spouse/ Domestic Partner Birthdate:___________
Date Property Purchased / Occupied:__________
If known: , Parcel /Tax Account #: ______________________________________
COMBINED DISPOSABLE INCOME CALCULATION: Attach copy of your complete IRS return, copies of 1099s and include income
from spouse/domestic partner or co-tenant(s). See reverse for more detail. While all income sources must be disclosed, not all income
sources are included in the final combined disposable income calculation.
Failure to comply may result in delay or denial of application
Public Assistance or Alimony Rec’d
Total Earned Wages
NET Social Security
Money received from another Country
VA Benefit or Disability Income
Money received from family
Retirement and Pension Income
Money earned by a co-tenant
IRA or Annuity Disbursements
Any other financial resources
Taxable & Non-Taxable Interest or
Dividends (Schedule B)
NON-REIMBURSED EXPENSES (DEDUCTIONS)
Business Income before Depreciation
- Assisted living facility/Adult Family Home
Capital Gains (DO NOT deduct
- In-Home Care OR
ANY Capital Losses)
Nursing Home Expenses
- Non-Reimbursed Prescription Costs OR
Rental Income before Depreciation
Approved Medicare plans
- IRS Form 1040 (line 36 deduction) OR
Trust, Partnership, Estate or Royalty
1040A (line 20 deduction)
NET TOTAL 2016 INCOME:
Taxable & Non-Taxable Bonds
Documentation of income and expenses must be included
Spouse/Domestic Partner/Co-Tenant Name:
City, State, Zip:
Mailing Address if different:
Any exemption granted through willfully providing erroneous information shall be subject to the correct tax being assessed for the last three (3)
years, plus a 100% penalty, (RCW 84.40.130). I declare under the penalties of perjury, that all of the foregoing statements are true.
Your signature must be witnessed by two (2) people OR by one (1) Deputy Assessor.
For Department Use Only:
Ex Level: S
DOA Form 9210 (Rev 12/29/16)