Form Rp-459-B - Application For Partial Exemption For Real Property Of Physically Disabled Crime Victims - 2001 Page 2

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RP-459-b rev. (11/01)
2
11. Copy of police report, report from Office of Victim Services or other documentation substantiating that
disability resulted from a crime is attached.
Yes
No
I certify that all statements made above are true and correct.
Signature of Owner (or Owner’s Representative * )
Date
* If owner is physically unable to complete this form, it may be completed by the owner’s spouse, child or parent,
or by some other representative of the owner. Explain representative’s relationship to the owner.
Section 2:
1. _____________________________
________________________
____________________
Physician’s name
New York State License no.
Date of Issue
2. __________________________________________________________________________________________
Office address
3. _____________________________
Patient’s name
4. Patient’s address: __________________________________________________________________________
5. a. Does patient have a permanent physical impairment which substantially limits one or more major life
activities (e.g. walking)?
Yes
No
b. If yes, description of patient’s permanent physical disability:
6. Explain how improvement to real property facilitates and accommodates patient’s use and accessibility of
property:
I certify that all statements made in this section are true and correct to the best of my knowledge and professional
belief.
____________________________________________
__________________________
Signature of physician
Date
Clear Form
SPACE BELOW FOR ASSESSOR’S USE
Date application filed_____________________
Application approved
Application disapproved
Applicable taxable status date______________________________
(a) Assessed valuation of parcel including value attributable to improvements made to
facilitate use and accessibility of property by physically disabled person ...........................$ ______________
(b) Assessed valuation of parcel excluding value attributable to improvements made to
facilitate use and accessibility of property by physically disabled person ...........................$ ______________
Assessed valuation of exemption granted [ (a) less (b) ] .................................................... $ ______________
______________________
____________________________________________
Date
Signature of assessor

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