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62A350 (12-11)

APPLICATION FOR EXEMPTION

Commonwealth of Kentucky

UNDER THE HOMESTEAD/DISABILITY AMENDMENT

DEPARTMENT OF REVENUE

Please print or type all requested information.

County __________________________________________________

Date Submitted ___________________________

Application is hereby made for the homestead exemption provided by Section 170 of the Kentucky Constitution.

Name(s) of owner-applicant(s) in whose name(s) title is vested: __________________________________________________

__________________________________________________________________________________________________________

Name of applicant(s)

Date of birth

Age

Sex

Relationship to other occupants

________________________________ ______________

_____

____

 Husband  Wife  Other ________

________________________________ ______________

_____

____

 Husband  Wife  Other ________

________________________________ ______________

_____

____

 Husband  Wife  Other ________

Address of personal residence

_____________________________________________________________________________

City ___________________________ State _______________ Zip Code ______________

Description ________________________________________________________________________________________________

Mailing address (if different from above) ______________________________________________________________________

Phone Number _____________________________________________

Date of Ownership ___________________________

4. Have you applied for, or are you receiving, the homestead exemption in a different location, county, or state?

 yes  no If “yes”, where? _____________________________________________________________________________

Type of residential unit:  single family residence  duplex  apartment building  mobile home  condominium

 other (describe) _________________________________________________________________________________________

Type of ownership:  fee simple  equitable title  jointly with survivorship  jointly in common  by stock

ownership or membership representing the owner’s or member’s proprietary interest in a multi-family structure

Note: Amount of exemption: If ownership is fee simple, equitable title, jointly with survivorship or jointly in common, applicant

receives full exemption or up to the assessed value of his interest in the property, whichever is less. If ownership is by stock

ownership or membership, the amount of exemption is full exemption or the percentage that the applicant’s ownership bears to

the total value of the property. (Example: Total value of the structure = $50,000; applicant’s stock ownership = 10%; exemption

limit = $5,000.)

AFFIDAVIT AND OATH

I, ______________________________________ , hereby swear (affirm) under penalty of perjury that I (we) am (are) the owner(s)

of the property for which this assessment exemption is sought and that I (we) do not or will not claim an exemption for any

other property in this Commonwealth or another state. I further swear (affirm) that I (we) maintain this residential unit as

my (our) primary residence; that I (we) am (are) 65 years of age or over, or totally disabled; and that all information contained

in this application is true and correct.

If qualifying under the disability provision under KRS 132.810(2), I do further swear (affirm) under penalty of perjury that my

disability is continuing and that if my disability status changes and benefits are no longer received I shall report such changes

to the property valuation administrator’s office as required by KRS 132.810(4)(b). Failure to do so could result in supplemental

bills being issued for the amount of the exemption received for up to a period of five years.

Signature of Applicant

Date

Signature of Spouse

Date

RESERVED FOR OFFICIAL USE

This application is  approved  disapproved.

Map Number _________________________________

Account Number _____________________________

Property Valuation Administrator

Date

(See Explanation on Reverse)

Form 62a350 - Application For Exemption Under The Homestead/disability Amendment(2011)

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