Form Ea-923 - Third Party Notification For Real Property Taxes Application Page 2
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1
2FORM
NEW YORK CITY
DEPARTMENT OF FINANCE
PROPERTY DIVISION
G
G
REQUEST FOR MAILING OF DUPLICATE TAX BILLS
EA-923
OR STATEMENTS OF UNPAID TAXES TO A THIRD PARTY
Mail to: NYC Department of Finance, Property Division, 66 John Street, 12th Floor, New York, NY 10038
I request that a duplicate of any tax bill or statement of unpaid taxes with respect to my property as described below be mailed
to the person whom I have designated. In making this request, I understand that neither the tax collecting officer nor any other
local government employee has any liability if for any reason the duplicate is not mailed to or not received by my designee.
SECTION 1: TAXPAYER INFORMATION
Taxpayer Name: __________________________________________________________________________________________________
Mailing Address: _________________________________________ City & State:________________________ Zip Code: _____________
Property Identification (as shown on assessment roll): _____________________________________________________________________
Tax Billing Address (if different than mailing address): _____________________________________________________________________
K
K
The Applicant is (check one):
At least 65 years of age
OR
Disabled*
_________________________________________________________
________________________________
Signature
Date
SECTION 2: THIRD PARTY DESIGNEE
Third Party Name: __________________________________________________ Daytime Telephone:_____________________________
Mailing Address: ________________________________________ City & State:________________________ Zip Code: _____________
_________________________________________________________
________________________________
Signature
Date
SECTION 3: PHYSICIANʼS CERTIFICATION FOR AGED OR DISABLED APPLICANTS
*If you checked “Disabled”, this section must be completed.
Physician’s Name: ________________________________________________________________________________________________
Office Address: _________________________________________ City & State:________________________ Zip Code: _____________
NYS License Number: ______________________________________________
Date of Issue _______________________________
Patient’s Name: ___________________________________________________________________________________________________
Patient’s Address: _______________________________________ City & State:________________________ Zip Code: _____________
Does patient have a physical or mental impairment which substantially limits
one or more major life activities (e.g., walking)? ............................................................................................
K YES
K NO
Please describe. _____________________________________________________________________________________________
I certify that all statements made in this section are true and correct to the best of my knowledge and professional belief.
_______________________________________________________
_________________________________
Signature of Physician
Date
Form EA-923 Rev. 08/27/09
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