Form Boe-261-G - Claim For Disabled Veteran'S Property Tax Exemption - 2007 Page 2
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4BOE‑261‑G (S1B) REV. 14 (8‑07)
StAtEmENtS
This claim form may be used to file for the Disabled Veterans’ Exemption for the Assessment Roll and the Supplemental Assessment Roll.
Separate claims may be required for each roll. Please carefully read the information and instructions before answering the questions listed
below. If you received the Disabled Veterans’ Exemption last year and are filing this form solely to claim the $166,944 Exemption, check
here
and proceed directly to item 4.
1. a. When did you acquire this property?
.
(month/day/year)
b. Date you occupied or intend to occupy this property as your principal residence:
.
(month/day/year)
c. Have you claimed the exemption on the home where you most recently resided?
Yes
No
If yes, see Question 1d below.
d. Has that home been sold or transferred?
Yes
No What is the address of that home, including the city and county where
the home is located?
Address:
City:
County:
2. a. Date filed for disability rating with the USDVA*?
.
b. Date received disability rating from the USDVA*?
.
c. Effective date of disability rating from the USDVA*?
.
*United States Department of Veteran Affairs
3. The basis for this claim is (please check the appropriate boxes):
a.
Blind in both eyes (blind means having a visual acuity of 5/200 or less, or concentric contraction of the visual field to
5 degrees or less; proof is attached);
b.
Disabled because of loss of use of 2 or more limbs (loss of the use of a limb means that the limb has been amputated, or its use
has been lost by reason of ankylosis, progressive muscular dystrophies, or paralysis; proof is attached);
c.
Totally disabled as a result of a service‑connected
injury or
disease (totally disabled means that the United States
Veterans Administration or the military service from which discharged has rated the disability at 100 percent or has rated the
disability compensation at 100 percent by reason of being unable to secure or follow a substantially gainful occupation; proof is
attached);
d.
Unmarried surviving spouse of a deceased veteran who during his or her lifetime qualified for this exemption or who would
have qualified for this exemption under the laws effective on January 1, 1977 (January 1, 1979, for disease) except that
the veteran died prior to January 1, 1977 (January 1, 1979, for disease). Disability:
blindness;
loss of use of two or
more limbs;
total disability because of injury; or
total disability because of disease (check applicable box; proof of
disability, copy of mar riage license, and copy of death certificate must be submitted to the Assessor). My spouse died on
.
(month/day/year)
e.
Unmarried surviving spouse of a person who, as a result of service‑connected injury or disease, died while on
active duty in the military service (copy of marriage license, proof that the cause of death was service‑connected, dates
of service, and copy of death certificate or report of casualty must be submitted to the Assessor). My spouse died on
.
(month/day/year)
4. To be completed only by claimants for the $166,944 Exemption:
My yearly household income (see the instructions) for the prior calendar year was $
. (If the amount entered
does not exceed $49,929, the exemption becomes $166,944 of assessed value. If you enter an amount greater than the limit, or you
do not enter an amount, the Assessor will allow an exemption of up to $111,296 of assessed value.)
Telephone No. (8 a.m. - 5 p.m.)
cERtiFicAtiON
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing
and all information hereon, including any accompanying statements or documents, is true,
correct and complete to the best of my knowledge and belief.
SIGNATURE OF PERSON MAKING CLAIM
DATE
t
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