Form Ex-01 - Exemption Application For Owners - 2013-2014 Page 2
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3Exemption Application for Owners
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SECTION 5 - DISABILITY INFORMATION
YES
NO
Do any of the owners, their spouse or registered domestic partner receive any disability income, such
as: Social Security Disability Insurance, Supplemental Security Income, Railroad Retirement Disability
Benefits or a Disability Pension?
If you checked YES, please submit one of the following REQUIRED documents:
Copy of the award letter from the Social Security Administration
Copy of the award letter from the Railroad Retirement Board or the U.S. Postal Service
G
Copy of a certificate from the State Commission for the Blind and Visually Handicapped
G
G
If YES, list years of service.
Ex: 1965 - 1972
SECTION 6 - VETERAN INFORMATION
YES
NO
1. Are any of the owners a veteran?
Are any of the owners a spouse or unremarried widow/er of a veteran?
Are any of the owners a registered domestic partner of a veteran?
Are any of the owners a parent of a soldier killed in action?
If you checked YES to any box, please submit the following REQUIRED document for each veteran:
Copy of the DD-214 or separation papers
G
YES
NO
2. Did the veteran serve in a combat zone or theater?
If YES, where did the veteran serve? (provide proof of service)
YES
NO
3. Was the veteran disabled in the line of duty?
If you checked YES, please submit the following REQUIRED document for each veteran:
Copy of a letter from the VA documenting the disability rating for each veteran.
G
SECTION 7 - CLERGY INFORMATION
YES
NO
1. Are you an active member of the clergy who is primarily responsible for ministerial work?
If you are not active:
YES
NO
2. Were you unable to perform such work due to an illness or impairment?
3. Are you over age 70?
4. Are you the surviving unremarried spouse of the clergy member?
If you checked YES to any box, submit the following REQUIRED document for each clergy member:
verification letter from the church employer
G
In addition, the following documentation is required:
Physicianʼs statement. (If you checked yes to box 2)
Copy of a government-issued ID, birth certificate or baptismal certificate. (If you checked yes to box 3)
G
Copy of your marriage certificate and a copy of your spouseʼs death certificate. (If you checked yes to box 4)
G
G
SECTION 8 - SIGNATURES - CERTIFICATION
By signing below, I certify that all statements made on this application are true and correct to the best of my knowledge and that I have made no willful false
statements of material fact. I understand that this information is subjected to audit and should Finance determine that I do not qualify for tax exemption, I
will be disqualified from future exemptions and will be responsible for all applicable taxes due, accrued interest, and the maximum penalty allowable by law.
ALL OWNERS MUST SIGN AND DATE THIS APPLICATION, WHETHER THEY RESIDE ON THE PROPERTY OR NOT
If there are more than two owners, please complete the Additional Ownersʼ Sheet.
#1
OWNER
: ___________________________________________
: ____________________________
SIGNATURE
DATE
#2
OWNER
: ___________________________________________
: ____________________________
SIGNATURE
DATE
CONTACT INFORMATION
If we have a question about this application, whom should we contact?
Contact Name: ______________________________________________________________________________________
Telephone #: _________________________________
E-Mail Address: ______________________________________
* PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR RECORDS *
The Department will inform you of all exemptions benefits that you are eligible for on your Statement of Account.
PRIVACY ACT NOTIFICATION - Under the Federal Privacy Act of 1974, if we ask you to give us your social security number, we must tell you whether or not you are obligated to provide us with the
social security number, our legal right to ask you for the information, and how we plan to use it. You must list you taxpayer identification number (SSN or EIN) in order to apply for an exemption from
real property taxes. We are asking this information to make sure that out records are accurate, and that you have submitted accurate information. Our legal right to require this information is contained
in Section 1-102.1 of the Administrative Code. This authorizes the Department of Finance to require any person to provide taxpayer identification number so that we may administer and collect taxes.
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