Senior Citizen Property Tax Exemption Application Form (Page 2 of 3) in pdf

Senior Citizen Property Tax Exemption Application

Page 5

SECTION 2 - INCOME STATEMENT

1. Did any owner have to file a federal income tax return for the last calendar year? ....................

YES

If "YES", YOU MUST ATTACH A COMPLETE COPY OF THE TAX RETURN INCLUDING ALL SUPPLEMENTARY SCHEDULES.

2. Complete the income statement if any of the following is true: 1) at least one owner of the property did not file a

federal income tax return for the last calendar year; or 2) you did not itemize medical and prescription expenses on

the federal income tax return which you wish to claim as a deduction against income for this exemption; or 3) you

are recipient of a Veterans Administration disability pension which is excluded from the definition of income for this

exemption. State total income of each applicant. If more space is required, attach an additional statement.

ALL INCOME IS SUBJECT TO VERIFICATION.

H o u s e h o l d

I n c o m e

A m o u n t

3. I n c o m e S o u r c e for C a l e n d a r Y e a r 1 9 ____

A - Applicant

B - Spouse

C - Other Applicant

a. Social Security (must attach FSA 1099 statement)..................

b. Salary or wages, including part-time employment ..................

c. Interest ..................................................................................

d. IRA Distribution (DO NOT INCLUDE ROLLOVERS)..................

e. Nontaxable interest on state or local bonds ............................

Dividends.................................................................................

g. Net income of property (from page 6, Section 3) .......................

h. Capital gains ...........................................................................

Gains from sales or exchanges ...............................................

Net earnings from business or profession ..............................

k. Net income from estates or trusts ..........................................

Government or private retirement or pension plan payments ..

m. Alimony or support money .....................................................

n. Disability payments (DO NOT INCLUDE VETERANS

ADMINISTRATION DISABILITY PENSION) ..............................

o. Workers compensation ...........................................................

p. Foreign holdings (REFER TO DEFINITION PROVIDED FOR ON

PAGE 3 IN SECTION 2 AND SPECIFY:___________________

q. Other (specify: __________________________________ )..

TOTAL (add lines a through q) ................................................

4. If any of the applicants have unreimbursed medical and/or unreimbursed prescription drug expenses for the above

calendar year, including charges not covered due to a deductible provision of your insurance coverage, enter the

total of such expenses for each applicant in the appropriate column below. ATTACH COPIES OF BILLS, RECEIPTS

AND STATEMENTS FROM THE APPLICANT'S INSURANCE CARRIER(S) WHICH DOCUMENT THE TOTAL UNREIM-

BURSED MEDICAL AND/OR PRESCRIPTION DRUG EXPENSES CLAIMED.

U n r e i m b u r s e d m e d i c a l / p r e s c r i p t i o n e x p e n s e s

A - Applicant

B - Spouse

C - Other Applicant

a. Medical Expenses: ...................................................................

b. Prescription Expenses: ............................................................

c. Medical Insurance Premiums...................................................

d. Total Expenses: .......................................................................

5. A d j u s t e d I n c o m e T o t a l

a. Subtract Line 4d for each applicant from 3r above . This is

your total adjusted income. If no deductions are claimed,

carry down total from Line 3r...................................................

TOTAL HOUSEHOLD INCOME (ADD LINE 5A OF COLUMNS A, B AND C)

Senior Citizen Property Tax Exemption Application Form Page 2

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