Form Ptr-1a - Verification Of 2000 And 2001 Property Taxes For Property Tax Reimbursement Applicants

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FORM PTR-1A
Homeowners
Verification of 2000 and 2001 Property Taxes for
Property Tax Reimbursement Applicants
Social Security Number
Spouse’s Social Security Number
First Name
__________________________
Last Name _______________________________
Address
_____________________________________________________________________
_____________________________________________________________________
Block
_______________
Lot __________
Qualifier ____________________________
2000 Property Taxes
2001 Property Taxes
1. Total Amount Paid
$ ______________
1. Total Amount Paid
$ _____________
2. Senior Citizen’s Deduction $ ______________
2. Senior Citizen’s Deduction $ _____________
3. Veteran’s Deduction
$ ______________
3. Veteran’s Deduction
$ _____________
4. Total Amount Due
$ ______________
4. Total Amount Due
$ _____________
(Enter on Line 11, Form PTR-1)
(Enter on Line 10, Form PTR-1)
I certify that I am the local tax collector of ______________________________________________,
where the above property is located. I further certify that the above stated amounts of property taxes
due and paid for calendar years 2000 and 2001 are true and accurate to the best of my knowledge. I
have placed my stamp below for verification.
__________________________________________
(Name)
__________________________________________
(Title)
(If you complete this form, be sure to enclose it with your Form PTR-1 application)

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