Appeal Of Denial Of A Senior Or Veteran Exemption Form printable pdf download

TC106A

TAX COMMISSION OF THE CITY OF NEW YORK

2015

1 Centre Street, Room 2400, New York, NY 10007

APPEAL OF DENIAL OF A SENIOR OR VETERAN EXEMPTION

COMPLETE ALL PARTS OF THE FORM. NO APPEAL WILL BE REVIEWED WITHOUT PROOF, AS DETAILED BELOW. THE APPLICATION MUST BE

RECEIVED BY THE TAX COMMISSION – NOT THE DEPARTMENT OF FINANCE- BY MAY 31, 2015. YOU MUST ATTACH A COPY OF YOUR APPLICATION

FOR EXEMPTION FILED WITH THE DEPARTMENT OF FINANCE, AND ANY NOTICE DENYING AN EXEMPTION. IMPORTANT-CAREFULLY READ

INSTRUCTIONS ON THE BACK TO CALCULATE HOUSEHOLD INCOME, WHICH IS NOT THE SAME AS ADJUSTED GROSS INCOME.

1. PROPERTY IDENTIFICATION

BOROUGH (Bronx, Brooklyn, Manhattan, Queens or Staten Island)

BLOCK

LOT

ASSESSMENT YEAR

2015/16

Type of Residence (check one):



1-, 2-, 3-family dwelling _ Condominium Unit

Cooperative - Unit # _____________________ and the number of shares: #______________.



Other (please specify): ___________________ and the percent of space used for primary residence:_______%

FULL ADDRESS OF PROPERTY AND APARTMENT NUMBER IF THE PROPERTY IS COOPERATIVE HOUSING (INCLUDE ZIP CODE)

________________________________________________________________________________________________________________________

2. OWNER INFORMATION - The applicant must be an owner using the property as their primary residence. If there is

more than one owner, a TC106A Supplemental must be completed by each and attached.

Name of owner _____________________________________________________________________________________________

Social Security Number ______________________

Date of Birth ________________

3. CONTACT INFORMATION

PHONE NO.

NAME OF PERSON TO BE CONTACTED

MAILING ADDRESS

EMAIL ADDRESS

4. SENIOR EXEMPTION (SCHE) CLAIM (YOU CANNOT GET BOTH SCHE & DHE)



This property is my primary residence Y



I am receiving an exemption on another property Y

My household income for 2013 was __________ (See instructions to calculate.)

Proof Attached Y N No appeal will be reviewed without the required proof.



Copy of a Government-issued ID such as a Driver’s License. Y

Copies of receipts for unreimbursed medical or prescription expenses. Y



Copies of 2013 federal tax returns or an indication why any owner is not required to file. Y

STATE TAX RETURNS ARE NOT ACCEPTABLE.

5. DISABLED EXEMPTION (DHE) CLAIM



This property is my primary residence Y



I am receiving an exemption on another property Y

My household income for 2013 was __________(See instructions to calculate.)



Proof Attached Y

No appeal will be reviewed without the required proof



Copies of 2013 federal tax returns or an indication why any owner is not required to file. Y

STATE TAX RETURNS ARE NOT ACCEPTABLE



Copies of receipts for unreimbursed medical or prescription expenses. Y

Copy of one of the following for an owner: the 2013 award letter from the

Social Security Administration, the Railroad Board or the U.S. Postal Service , or a Certificate from the State Commission for the Blind and Visually



Handicapped. Y

6. ATTACHMENTS - List whatever you’re attaching as proof. Number the pages.

________________________

_________________________

________________________

_________________________

Last page number __________

7. OATH

This application must be signed by an individual having personal knowledge of the facts. If the signer is not the applicant, an explanation should be provided, as

well as the signer’s basis of personal knowledge.

Print name of person signing ___________________________________

I have read this form and all relevant instructions, whether on this form, or on another. I certify that all statements made on this application,

including the attached sheet(s) totaling _____ pages detailed above, are true and correct to the best of my knowledge and belief, and I understand

that such statements are being relied upon by the City of New York, and that they are subject to verification. I have read this entire form before

signing it. I am personally responsible for the accuracy of the information provided on this application, and any attachments. I also understand that

the making of any willful false statement of material fact on this application including the attached sheet(s) will subject me to the provisions of the

penal law relevant to the making and filing of false statements.

Signed: __________________________________________________________ Date:__________________

The signer must appear and acknowledge the signature before a notary.

Sworn to before me:

County __________________________ State ___________________________ Date: _________________

NOTARY STAMP

Signature of person administering oath ________________________________________________________