Part III. Affirmation and Signature(s)
Under penalty of law, I/we affirm that I/we are owners of the property on which we are applying for the property tax
benefit, that I/we occupied the property as my/our primary residence for at least seven months during the preceding
calendar year and that the information 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
q
q
_____________________________________
_______________________
_____________________________________
_______________________
q
q
q
q
_____________________________________
_______________________
_____________________________________
_______________________
q
q
_____________________________________
_______________________
q
q
Part IV. Head of Household Information (To be completed by the applicant if filing as Head of Household.)
Name of Dependent
Social Security Number
________________________________________________
_________________________
________________________________________________
_________________________
________________________________________________
_________________________
________________________________________________
_________________________
Part V. For Department Use Only
Geocode ______________________________
School District __________________________
Assessment Code _______________________
Granted:
q Yes
q No
Applicants’ Income
Class Codes
Percent
Multiple
Reduction
Single
or
Land
Imp
Mob
Head of Household
80
2132
3137
6237
$
0 - $8,324 $
0 - $11,098
50
2135
3140
6240
$ 8,325 - $12,763 $ 11,099 - $19,422
30
2137
3142
6242
$ 12,764 - $20,809 $ 19,423 - $27,745
PPB-8
Rev. 10 12