Form Ppb-8a - Disabled American Veteran Property Tax Relief Application Page 2

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Part III. Affidavit of Disabled American Veteran

I affirm that I have been honorably discharged from active service in the armed forces, and I am currently rated 100%

disabled or paid at the 100% disabled rate because of a service-connected disability. I also affirm that I own and occupy

the property that I am asking to be exempted, and my federal adjusted gross income is not more than $47,865 if I am

single or $55,229 if I am married or filing as the head of a household.

My/our income tax filing status for 2012 is:

Single

Married

Head of Household (see Part VI)

Federal Adjusted Gross Income ............................................................................................................ $ ______________

Part IV. Affidavit of Surviving Spouse of Disabled American Veteran

I affirm that I am the surviving spouse of a veteran who was 100% service-connected disabled or paid at the 100%

disabled rate at the time of death, died while on active duty, or died as a result of a service-connected disability, and I

have remained unmarried. I further affirm that I own and occupy the property that I am asking to be exempted, and my

federal adjusted gross income as reported on my federal income tax return is not more than $41,729.

My income tax filing status for 2012 is:

Single

Married

Head of Household (see Part VI)

Federal Adjusted Gross Income ............................................................................................................ $ ______________

Part V. Affirmation and Signature(s)

Under penalty of law, I affirm that the information that I have provided in this application form is true and correct.

This completed affirmation and signature page must be returned with the appropriate income documentation or your

application may be denied.

Signature

Social Security Number

Income

Filing an

documentation income tax

provided

extension

_______________________________________