State Tax Form 96 - Senior - Surviving Spouse Or Minor - Veteran - Blind - Application For Statutory Exemption - 2011 Page 4

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. Complete this section if you are a (1) surviving spouse, (2)
D. VALUE OF ALL PROPERTY OWNED ON JULY 1 THIS YEAR
minor child of a deceased parent, or (3) senior. Documentation may be requested to verify your assets.
Assessed Valuation
Amount Due on Mortgage
Value
Real Estate
Domicile
Other
Personal Estate
Bank Accounts: Name & Address of Bank
Stocks, Bonds, Securities, etc.: Description & Amount
Motor Vehicles & Trailers: Year, Make & Model
Other Non-exempt Personal Property: Kind & Description
TOTAL
GO ON TO SECTION E
E. SIGNATURE. Sign here to complete the application.
This application has been prepared or examined by me. Under the pains and penalties of perjury, I declare that to the
best of my knowledge and belief, this return and all accompanying documents and statements are true, correct and
complete.
Signature
Date
If signed by agent, attach copy of written authorization to sign on behalf of taxpayer.

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