State Tax Form 96-2 - Surviving Spouse Or Minor Application For Statutory Exemption - 2009 Page 2
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3B. EXEMPTION STATUS. Complete the questions that follow.
Deceased Spouse’s Name
SURVIVING SPOUSE
Date of Death
Have you remarried?
Yes
No
If yes, date of remarriage ____________
Deceased Parent’s Name
MINOR WITH PARENT DECEASED
Date of Death
If first year of application, attach a copy of death certificate.
Yes
No
Are you a surviving spouse or a minor child of a firefighter or a police officer killed in the line of duty?
IF NO, GO ON TO SECTION C
If yes, and this is the first year of application, provide circumstances of death.
GO ON TO SECTION D
C. VALUE OF ALL PROPERTY OWNED ON JULY 1 THIS YEAR. Complete this section. Documentation may be
requested to verify your assets.
Assessed valuation
Amount due on mortgage
Value
Real Estate
Domicile
______________________________________
_____________________________
______________
Other
______________________________________
_____________________________
______________
Bank accounts: Name & address of bank
Value
Personal
________________________________________________________________________
______________
Estate
________________________________________________________________________
______________
________________________________________________________________________
______________
Stocks, bonds, securities, etc.: Description & amount
Value
________________________________________________________________________
______________
________________________________________________________________________
______________
________________________________________________________________________
______________
Motor vehicles & trailers: Year/Make/Model
Value
________________________________________________________________________
______________
________________________________________________________________________
______________
Other non-exempt personal property: Kind & description
Value
________________________________________________________________________
______________
________________________________________________________________________
______________
TOTAL
______________
GO ON TO SECTION D
D. 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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