Application For Real Estate Tax Exemption For Elderly Or Permanently/totally Disabled Homeowners Form Page 2
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4City of Winchester, Tax Relief Application: _________________________________________________________________
Type of exemption for which you are applying
Elderly
Disabled
Required Attachments: You must include this information for your application to be complete
List of Vehicles with Make, Model and Year
List of Other Real Estate Owned (if applicable)
Proof of all Income and Assets
Proof of Liabilities (if applicable)
Power of Attorney (if applicable)
Attached: _____
To Follow: _____
Provided in Year: _______
Federal/State Tax Return for previous year (If you do not file, please mark here ____)
If under 65, you must provide certification of disability every 5 years. Please mark status of certification(s)
Social Security Awards Letter Attached: _____
To Follow: _____
Provided in Year: _______
Veterans Administration
Attached: _____
To Follow: _____
Provided in Year: _______
Railroad Retirement Board
Attached: _____
To Follow: _____
Provided in Year: _______
Affidavit of Two Physicians
Attached: _____
To Follow: _____
Provided in Year: _______
APPLICANT: ______________________________________________________________________________________
(Property Owner)
(Last Name)
(First Name)
(Middle Name)
Property Street Address: _____________________________________________________________________________
Applicant Birth Date: ___________________________ Social Security Number: ________________________________
SPOUSE \ CO-OWNER: ____________________________________________________________________________
(Note if “None” or “Deceased”)
(Last Name)
(First Name)
(Middle Name)
Spouse Birth Date: ____________________________ Social Security Number: _______________________________
Applicant Telephone_______________________________________
Name on Real Estate Tax Bill, if different from Applicant Name: _____________________________________________
Applicant is: ____ Sole Owner
____ Partial Owner, Property legally held as: __________________________________________________
If property is multi-unit or mixed use, portion used as applicant’s dwelling: ___________________________ %
*Optional: Friendly Contact Name: _________________________________
Phone: _________________________
Other Contributing Members of Household:
List the name, relationship, age and social security number of all contributing members of the dwelling, whether
related or not.
Name
Relation to Applicant
Age
Social Security
Number
(Please complete other side of this form)
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