Application For Real Estate Tax Exemption For Elderly Or Permanently/totally Disabled Homeowners Form (Page 4 of 4) in pdf

Application For Real Estate Tax Exemption For Elderly Or Permanently/totally Disabled Homeowners Form Page 4

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)

Page 4 of 4

Application For Real Estate Tax Exemption For Elderly Or Permanently/totally Disabled Homeowners Form Page 4