Form Ptr-1a - Homeowners Verification Of 2015 And 2016 Property Taxes
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1Form PTR-1A
Homeowners
Verification of 2015 and 2016 Property Taxes
(Use blue or black ink. See instructions for completion on back.)
Part I — To Be Completed by Applicant (Part II to be completed by tax collector)
Social Security #
–
–
Spouse’s/CU Partner’s Social Security #
–
–
Name
Last Name, First Name, and Initial (Joint filers, enter first name and initial of each - Enter spouse’s/CU partner’s last name ONLY if different)
Address
Street
City
State
Zip Code
Block
Lot
Qualifier
2015
2016
A. Did you own this property with someone who was not your spouse/CU partner?
Yes
No
Yes
No
B. If yes, indicate the share (percentage) of property that you (and your spouse/CU partner) owned.
%
%
C. Did this property consist of multiple units?
Yes
No
Yes
No
.
%
%
D. If yes, indicate the share (percentage) of property used as your principal residence
Part II — To Be Completed by Tax Collector
2015 Property Taxes
2016 Property Taxes
Check box if property had a tax appeal for 2016 . . . . . . . .
Check box if property had a tax appeal for 2015 . . . . . . . .
Check box if property had an added assessment for 2016 .
Check box if property had an added assessment for 2015 .
1. Assessed Value . . . . . . . . . . . . . . . . . . . . . . . $ _________
1. Assessed Value . . . . . . . . . . . . . . . . . . . . . . . . $ _________
2. Tax Rate (including fire and other
2. Tax Rate (including fire and other
special tax rates). . . . . . . . . . . . . . . . . . . . . . . __________ %
special tax rates) . . . . . . . . . . . . . . . . . . . . . . . __________ %
3. Total Property Taxes
3. Total Property Taxes
(Multiply Line 1 by Line 2) . . . . . . . . . . . . . . . . $ _________
(Multiply Line 1 by Line 2). . . . . . . . . . . . . . . . $ _________
4. REAP Credit (if any). . . . . . $ ___________
4. REAP Credit (if any). . . . . . $ ___________
5. Enter amount from Line 3. If applicant
5. Enter amount from Line 3. If applicant
answered “Yes” to Questions A and/or C
answered “Yes” to Questions A and/or C
above, you must apportion the amount on
above, you must apportion the amount on
Line 3 when completing this line.
Line 3 when completing this line.
(See instructions on back.) . . . . . . . . . . . . . $ ___________
(See instructions on back.) . . . . . . . . . . . . . $ ___________
Homeowners, enter this amount
Homeowners, enter this amount
on Line 13 of your Form PTR-1
on Line 14 of your Form PTR-1
Under the penalties of perjury, 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 were paid for
calendar years 2015 and 2016 and are true and accurate to the best of my knowledge. I have placed my stamp below for
verification.
____________________________________________
(Name)
(Date)
____________________________________________
(Title)
(If you complete this form, be sure to enclose it with your Form PTR-1 application.)
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