Form Ex-01 - Exemption Application For Owners - 2011 Page 2
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1
2Exemption Application for Owners
Page 2
SECTION IV - ELIGIBILITY INFORMATION
1. a. Are any of the owners listed in Section I veterans, or a spouse,
unremarried widow or widower, or a registered domestic partner
YES
NO
K
K
of a veteran; or the parent of a soldier killed in action?
If “YES” to 1a, answer Questions 1b through 1d.
If “NO” to 1a, skip to Question 2.
b. Did the veteran serve during a period of conflict?
YES
NO
K
K
c. Did the veteran serve in a combat zone?
YES
NO
K
K
d. Was the veteran disabled in the line of duty?
YES
NO
K
K
e. If you checked “YES” to 1d, please indicate the
percentage of the veteranʼs disability:
________%
2. Are you an active or retired member of the clergy who is/was
primarily responsible for ministerial work or the unmarried surviving
YES
NO
K
K
spouse or registered domestic partner of a member of the clergy?
SECTION V - SIGNATURES AND CERTIFICATIONS
By signing below, I certify that all statements made on this application are true and correct to the best of my knowl-
edge and that I have made no willful false statements of material fact. I understand that this information is subject to
audit, and should Finance determine that I do not qualify for tax exemptions, I will be disqualified from future exemp-
tions and will be responsible for all applicable taxes due, accrued interest, and the maximum penalty allowable by law.
All owners must sign and date this application, whether they reside at the property or not.
___________________________________________________ _________/_________/________
ʼ
OWNER
S SIGNATURE
DATE
___________________________________________________ _________/_________/________
ʼ
OWNER
S SIGNATURE
DATE
___________________________________________________ _________/_________/________
ʼ
OWNER
S SIGNATURE
DATE
___________________________________________________ _________/_________/________
ʼ
OWNER
S SIGNATURE
DATE
___________________________________________________ _________/_________/________
ʼ
OWNER
S SIGNATURE
DATE
Contact Information:
If we have a question about this application, whom should we contact?
Contact Name: _____________________________________________________________________
Telephone #: _________________________ Email Address: _______________________________
PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR RECORDS.
The Department of Finance will inform you of all exemption benefits that you are eligible for on your Statement of Account.
PRIVACY ACT NOTIFICATION
Under the Federal Privacy Act of 1974, if we ask you to give us your social security number, we must tell you whether or not you are obligated to provide us with the
social security number, our legal right to ask you for the information, and how we plan to use it. You must list your taxpayer identification number (social security num-
ber or employer identification number) in order to apply for an exemption from real property taxes. We are asking for this information to make sure that our records
are accurate, and that you have submitted accurate information. Our legal right to require this information is contained in Section 11-102.1 of the Administrative Code.
This authorizes the Department of Finance to require any person to provide a taxpayer identification number so that we may administer and collect taxes.
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