City of Winchester, Tax Relief Application: _________________________________________________________________
Applicant’s Value
Spouse’s Value
Liabilities Against Assets
Mortgage (other than primary residence)
Taxes Due (other than primary residence)
Other Debts Against Assets included in
this application
Total Liabilities Against Assets:
(b) Total Combined Liabilities of Applicant and Spouse: $ __________________________________________
Net financial worth is computed by listing all assets of applicant and spouse (excluding value of residence with
up to one acre of land), then subtracting all liabilities against assets.
Total Combined Net Financial Worth of Applicant and Spouse (“a” minus “b”): $ ________________________
Applicant’s Certification of Qualification
I declare under the penalties provided by law that the information contained in this application for Real
Estate Tax Relief for the Elderly or Disabled, including any accompanying schedules or statements, is
true, correct and complete. I certify that I meet all qualifications listed on Page 1 of this application. I
understand that I must meet all filing requirements and deadlines.
_______________
__________________________________
_________________________________
Date
Signature of Applicant
Signature of Spouse (if applicable)
Reference: Code of the City of Winchester §27-19 et seq.
------------------------------------------ OFFICE USE ONLY ------------------------------------------
Tax Acct No: _____________________
Total Income:
$ ________________
Tax Map No: _____________________
Total Net Worth: $ ________________
Application Status:
_____ APPROVED
Property Value $
x Dwelling %
x Tax Rate
x Exemption %
=Total Exemption
_____ DENIED for reason ___________________________________________________________________________
City Official Signature: ___________________________________________ Date: _____________________________
(Please complete other side of this form)
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