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10. If your income level is low enough that you are not required to file a Federal Income Tax Return,

enter your income for the preceding calendar year on this line. $ ______________

11. Enter below the required income information from your individual Federal Income Tax Returns

and attach the front page of your return. If you were not required to file a Federal return due to

income level, use other tax documents regarding questions 2-6 below, for the preceding calendar

year. For question 7, list income from all other sources other than gifts or inheritances from a

spouse, lineal ancestor, or lineal descendant. If you file a joint return, place all income

information under the claimant column.

CLAIMANT

SPOUSE

1. Adjusted Gross Income.

$__________

2. Tax exempt interest (not included in adjusted gross income)

$__________

3. IRA distributions (not included in adjusted gross income)

$__________

4. Pensions and Annuities (not included in adjusted gross income)

$__________

5. Social security benefits (not included in adjusted gross income)

$__________

6. Capital gains (not included in adjusted gross income)

$__________

7. All other moneys received. (not included in adjusted gross income)

$__________

TOTAL

$__________

Attach a copy of the first page of your individual Federal Income Tax Returns for the preceding calendar year.

If you have not filed at this time, please submit a copy of the first page at the time you file. While your income

tax returns are confidential and will be treated as such, you may block out any information except for those

items listed under #11 above. Your application for exclusion will not be processed until the income tax

information is received.

ALL INFORMATION IS SUBJECT TO VERIFICATION WITH THE NORTH CAROLINA

DEPARTMENT OF REVENUE.

AFFIRMATION OF CLAIMANT - Under penalties prescribed by law, I hereby affirm that to the best of my

knowledge and belief all information furnished by me in connection with this application is true and complete. I fully

understand that this application constitutes an attachment to my official tax listing for 2007 and that falsification on my

part as to any material fact on this application will subject me to the criminal penalties contained in G.S. 105-310 (A

class two misdemeanor).

Date Proof of Income Submitted________________

_____________________________________________

Claimant’s Signature

APPROVED______

DISAPPROVED_______

_____________________________________________

County Assessor’s Signature

Application must be received by June 1st.

Do not remit this to the North Carolina Department of Revenue. Please send

Completed form to the appropriate county tax office.

Form Av-9 Web - Application For Exclusion Under G.s. 105-277.1 - State Of North Carolina Page 2

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