Bfs-Rp-6b - Claim For Exemption - Totally Disabled Veteran (Sec. 8-10.6)

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Parcel 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: -FA at end of numbers
For example: 210630150000-FA
CLAIM FOR EXEMPTION
Totally Disabled Veteran (Sec. 8-10.6)
PRINT OWNER/APPLICANT’S NAME
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
SOCIAL SECURITY NUMBER
EMAIL ADDRESS
PROPERTY (PARCEL) ADDRESS
MAILING ADDRESS IF DIFFERENT FROM PROPERTY ADDRESS
Service entry date:____________________ Service discharge date: ____________________ Injury date: ________________________
Describe injury: ________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
CERTIFICATION
I certify the above facts to be true and that I am totally disabled due to injuries received while on duty with the armed forces of the United
States. I understand that I may be required to submit a physician’s report to provide proof of total disability. I hereby authorize the Real
Property Assessment Division to contact the Veterans Administration on my behalf for the limited purpose of verifying the dates of my
service entry, service discharge and injury, and my total disability.
_______ Yes
_______ No
(please check one)
I understand that if I do not authorize the Real Property Assessment Division to contact the Veterans Administration on my behalf, I may
be required to obtain the certification of the Veterans Administration myself to support this application.
___________________________________
______________________________
_______________________
SIGNATURE
PRINT NAME
DATE
Complete the Claim form and deliver or mail (post office cancellation mark) the claim form with supporting
documentation. Approved claims will be processed and take affect beginning with the next tax payment due. Submit
claim to:
Real Property Assessment Division
Real Property Assessment Division
842 Bethel Street, Basement
1000 Uluohia Street #206
Honolulu, HI 96813
Kapolei, HI 96707
Telephone: (808) 768-3799
Telephone: (808) 768-3169
This claim cannot be filed by facsimile transmission or via email. For a receipted copy, submit with a self addressed stamped envelope.
FOR OFFICIAL USE ONLY
For Tax Year: ______________________________________
Approved
Disapproved
Received By: ______________________________________
Date Received (post office cancellation mark): _____________________________
BFS-RP-6B (12/11)

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