Application For Tax Exemption Form Page 2
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1
2Account # ____________________
Applicant: (Deductions)
Co-Applicant: (Deductions)
Un reimbursed Medical Expenses
Un reimbursed Medical Expenses
(ex. Co-pays, exam’s, Dr. Bills)
(ex. Co-pays, exam’s, Dr. Bills)
Total: _________________________
Total: _____________________________
Un Reimbursed Prescriptions
UN Reimbursed Prescriptions
(You can obtain this from your Pharmacist)
(You can obtain this from your Pharmacist)
Total: ____________________________
Total: ______________________________
Health Insurance paid out of pocket:
Health Insurance paid out of pocket:
Total: ____________________________
Total: __________________________________
Name of Company: __________________
Name of Company: _________________________
Any other deductions can be listed below;
This application must be filled out completely to the best of your ability. Anything that may not apply to you
please write N/A in the space provided, otherwise we may think you forgot to include some information.
COPIES OF ALL ABOVE INFORMATION MUST BE SUPPLIED WITHIN ITS
ENTIRETY, UPON SUBMITTING APPLICATION.
All applications must be submitted with a certified copy of U.S. Federal Income Tax Return of
the current year. Even if you have to file zero, we must have a certified copy.
Applications for 100% disabled person’s must be submitted with a medical report or other
proof of disability.
APPLICATION WILL BE DENIED WITHOUT REQUIRED PROOF ATTACHED.
I SWEAR THAT THE FORE GOING INFORMATION IS TRUE, COMPLETE, AND
CORRECT.
APPLICANT: _______________________________________________________
Date: _______________________
CO APPLICANT: _____________________________________________________
Date: _______________________
Notary:
Subscribed and sworn to me this _________day of______________20______
In the (city/town) ___________________or Rhode Island.
Notary Signature: _______________________________________________
My Commission Expires on: ____________
Office use only
Total income: ___________ Total Deductions ______________
Amount of Gross Income: _____________________________
Approved ____________________
Denied__________________________________
INCOME BRACKET: $0--$8,000
EXEMPT. AMT. $10,000
<
$8001-$10,000
EXEMPT AMT. $7,000
CIRCLE ONE!
$10,001-$15,000
EXEMPT AMT $5,000
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