Rp Form 19-71 Claim For Home Exemption

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CASE NO. _______________________
RP FORM 19­71 (Rev. 07/2015)
TAX MAP KEY/PARCEL ID
DEPT. OF FINANCE
County of Hawai‘i
ISLE ZONE SEC PLAT
PAR
CPR
R e a l P r o p e r t y T a x D i v is ion
3
Aupuni Center  101 Pauahi Street  Suite No. 4  Hilo, Hawai‘i 96720  Fax (808) 961-8415
PLEASE READ INSTRUCTIONS ON
THE BACK BEFORE COMPLETING
Appraisers (808) 961-8354  Clerical (808) 961-8201
 Collections (808) 961-8282
THIS FORM
West Hawai‘i Civic Center • 74-5044 Ane Keohokalole Hwy.  Bldg. D, 2nd Flr.  Kailua Kona, Hawai‘i 96740
Fax (808) 327-3538 • Appraisers (808) 323-4881  Clerical (808) 323-4880
CLAIM FOR HOME EXEMPTION
CLAIMANT'S NAME (LAST, FIRST M.):
SPOUSE'S NAME (LAST, FIRST M.):
CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY):
SPOUSE'S DATE OF BIRTH (MM/DD/YYYY):
CLAIMANT'S LAST FOUR DIGITS SSN:
SPOUSE'S LAST FOUR DIGITS SSN:
STREET ADDRESS:
MAILING ADDRESS:
TELEPHONE: BUS:
HOME:
CELL:
E­MAIL:
1.
?
YES
NO
IS THERE MORE THAN ONE DWELLING UNIT ON THE PROPERTY
IF YES, DRAW A PLOT PLAN ON THE BACK OF THIS FORM. DESIGNATE WHICH DWELLING IS YOUR RESIDENCE, AND WHO OCCUPIES
THE OTHER DWELLING(S).
IS ANY PORTION OF YOUR PROPERTY USED FOR RENTAL OR BUSINESS PURPOSES (INCLUDING BED & BREAKFAST OR VACATION RENTALS)?
2.
YES
NO
IF YES, DESIGNATE THE FLOOR AREA OF THE PROPERTY USED FOR RENTAL AND/OR BUSINESS PURPOSES:______________SQ.FT.
TYPE OF BUSINESS:____________________________ LOCATION ON PROPERTY:_________________________________________
3.
HAVE YOU FILED A STATE OF HAWAI‘I RESIDENT INCOME TAX RETURN (N-11 OR N-13) WITHIN THE LAST 12 MONTHS?
YES
NO
IF NO, I AM REQUESTING A WAIVER FROM THIS REQUIREMENT FOR THE FOLLOWING REASON:
I AM A NEW RESIDENT TO THE STATE OF HAWAI‘I AND WILL FILE A STATE OF HAWAI‘I RESIDENT INCOME TAX RETURN (N-11
OR N-13) WITHIN THE NEXT 12 MONTHS. FAILURE TO FILE MAY RESULT IN A ROLLBACK OF ANY BENEFITS GRANTED.
I AM NOT REQUIRED TO FILE UNDER STATE OF HAWAI‘I INCOME TAX LAW AND AM NOT REQUIRED TO FILE INCOME TAX
IN ANY OTHER JURISDICTION OTHER THAN AT THE U.S. FEDERAL LEVEL.
YES
4.
DO YOU OR YOUR SPOUSE CLAIM A HOME EXEMPTION ELSEWHERE?
NO
IF YES, INDICATE TAX KEY NUMBER, PARCEL IDENTIFICATION, AND/OR ADDRESS:__________________________________________
THIS IS AN AUTHORIZATION TO CANCEL MY PREVIOUS EXEMPTION AND APPLY IT TO THIS NEW PARCEL
5.
IS ANY PORTION OF YOUR PROPERTY RECEIVING A PREFERENTIAL AGRICULTURAL USE ASSESSMENT AS PART OF A NON-DEDICATED OR
DEDICATED AGRICULTURAL USE PROGRAM?
YES
NO
SELECTING 'NO' IS AN AUTHORIZATION TO CANCEL ANY PREFERENTIAL AGRICULTURAL USE ASSESSMENTS APPLIED TO THIS PARCEL.
6.
SUBMIT THIS CLAIM WITH XEROX COPIES OF PROOF OF AGE FOR EACH OWNER-OCCUPANT, ACCEPTABLE PROOFS ARE DRIVER'S
LICENSE, STATE ID, BIRTH CERTIFICATE, SENIOR CITIZEN ID, PASSPORT, OR OTHER GOVERNMENT OR LEGAL DOCUMENT.
CERTIFICATION
I (WE) CERTIFY THAT I OWN AND OCCUPY THIS RESIDENCE AS MY PRINCIPAL HOME. THE PROPERTY IS NOT USED FOR MERE SPECIAL,
TEMPORARY, OR VACATION PURPOSES AND IS MY TRUE, FIXED PERMANENT HOME AND PRINCIPAL ESTABLISHMENT. ANY INDIVIDUAL
WHO FILES A FRAUDULENT CLAIM FOR EXEMPTION AND ATTESTS TO ANY FALSE STATEMENT, WITH THE INTENT TO DEFRAUD OR TO
EVADE THE PAYMENT OF TAXES OR ANY PART THEREOF, OR WHO IN ANY MANNER INTENTIONALLY DECEIVES OR ATTEMPTS TO DECEIVE
THE DEPARTMENT OF FINANCE, SHALL BE FINED $1,000. ANY PERSON WHO HAS BEEN ALLOWED AN EXEMPTION HAS A DUTY
TO REPORT TO THE ASSESSOR WITHIN 30 DAYS AFTER HE/SHE CEASES TO QUALIFY FOR SUCH EXEMPTION. FAILURE TO
SUBMIT SUCH A REPORT SHALL BE CAUSE FOR DISQUALIFICATION AND PENALTY.
CLAIMANT'S SIGNATURE
DATE
SPOUSE'S SIGNATURE
DATE
FOR DEPARTMENT USE ONLY
U.S. POSTMARK
OTC
FAX
DATE RECEIVED:_________________________ BY:________________________________
USPS EXTENDED ZIP _________________ DIFFERENCE IN MAILING ADDRESS:___________________________________________
NOTES
_____ PITT
_____ OVER/PITT
______ EX CD
______ CARD#
_____ BUILDING %
_____ LAND %
____ OTH H/EX CHK
Hawai'i County is an Equal Opportunity Provider and Employer

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