Application For Tax Exemption Form
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1
2Account # ____________________
TOWN OF
STATE OF
NORTH PROVIDENCE
RHODE ISLAND
J. Robert Battey
Charles Lombardi
ACTING TAX ASSESSOR
MAYOR
Application for Tax Exemption
Pursuant to Chapter III Public Laws of 1976
VARIABLE EXEMPTION APPLICATION FOR 2016
*THE INCOME OF A HUSBAND SHALL BE DEEMED TO INCLUDE THE TOTAL
INCOME OF HIS WIFE, AND THE INCOME OF A WIFE SHALL BE DEEMED TO
INCLUDE THE TOTAL INCOME OF HER HUSBAND**
Due on or before April 1st
Applicant: _____________________________
Co-Applicant: _________________________________
Phone: ___________________________________
Age: ____ DOB: ____/____/____ Lic. #________
Age: ____ DOB: ____/____/____ Lic. #____________
UNDER 65 MUST HAVE A DOCTOR’S LETTER STATING 100% DISABLED
S.S. #______________________________
S.S. # _____________________________
Address: ________________________________________________ Plat ___________ Lot ______________
Property Owned: Solely ( ) Jointly ( ) Are you a widow?
( )
( )
___ /____/____
YES
NO
Date spouse deceased
If owned Jointly with Whom? _______________________ Date Property was acquired: __________________
Do you own property in other City, Town, or State? If so where? ____________________________________
$15,000
COMBINED INCOME CAN NOT EXCEED
Applicant: (Income)
Co-Applicant: (Income)
Amount of SSI _____________________________ Amount of SSI _________________________________
(Please state if amount is yearly, monthly or annually?)
Employment Status/Amt. Earned_______________ Employment Status/Amt. Earned___________________
Pension earned ( if any) ______________________ Pension earned ( if any) __________________________
Rental income (if any) ________________________ Rental income (if any) ___________________________
Banking institute: ___________________________ Banking institute: ______________________________
Amt. Of Interest earned as of 12/31 $ ____________ Amt. Of Interest earned as of 12/31 $ ____________
Banking institute: ___________________________ Banking institute: ______________________________
Amt. Of Interest earned as of 12/31 $ ____________ Amt. Of Interest earned as of 12/31 $ ____________
Annuities/Ira’s/CD’s $ ____________________total Annuities/Ira’s/CD’s $ ___________________total
List each name/amt. ___________________________________ List each __________________________
Any other Income received. ____________________ Any other Income received. _______________________
CERTIFIED IRS FORMS MUST BE SUPPLIED! CERTIFIED IRS FORMS MUST BE SUPPLIED!
Total Gross Income Filed: $__________________
Total Gross Income Filed: $__________________
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