Crime Victim / Good Samaritan Exemption Application printable pdf download

Crime Victim / Good Samaritan Exemption Application

NYC DEPARTMENT OF FINANCE

PROGRAM OPERATIONS DIVISION

CRIME VICTIM/GOOD SAMARITAN

EXEMPTION APPLICATION

Finance

Mail to: NYC Department of Finance, P.O. Box 3120, Church Street Station, New York, NY 10008-3120

Instructions: Use this application if you are applying for a partial real property exemp-

tion for a disabled crime victim or Good Samaritan who incurred a disability as a result

of a crime and has modified a 1-, 2-, 3-family home to accommodate the disability.

SECTION I - OWNER INFORMATION

1. Owner #1ʼs Name:

a. _____________________________________ b. ___________________________________

FIRST NAME

LAST NAME

c. Is this Owner #1ʼs primary residence?

YES

d. Social Security #:

e. Date of Birth:

2. Owner #2ʼs Name:

a. _____________________________________ b. ___________________________________

FIRST NAME

LAST NAME

c. Is this Owner #2ʼs primary residence?

YES

d. Social Security #:

e. Date of Birth:

SECTION II - PROPERTY INFORMATION

1. Address: a. __________ b. _______________________________________ c. _____________

. #

STREET

STREET NAME

APT

2. Borough: ___________ 3. Block #: __________ 4. Lot #:__________ 5. Zip Code: ___________

SECTION III - ELIGIBILITY INFORMATION

Law enforcement officers are not eligible for this exemption.

1. Have any owners listed in Section I, their spouses, children, other family

members, or non-family occupants been disabled as a victim of a crime

YES

or while trying to prevent or assist during a crime (“Good Samaritan”)?

2. If you checked “YES” to Question 1, have improvements been made to the

YES

property to accommodate the personʼs special needs due to the disability?

3. If you checked “YES” to Question 1 and 2, indicate the cost of the

improvements made to the property?

$_______________

Visit Finance at nyc.gov/finance

Crime Victim Ex. Appl. Rev. 08.16.11

Crime Victim / Good Samaritan Exemption Application

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