Real Estate Tax Relief For Elderly And/or Totally Disabled Persons Application - City Of Alexandria - 2005 Page 2

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INCOME INFORMATION (FOR 1/1/2004 – 12/31/2004)
PROOF OF ALL INCOME MUST BE PROVIDED
APPLICANT AND SPOUSE
Applicant
Spouse
1
Social Security or Railroad Retirement
2
Pension
3
Annuity
4
Interest and Dividends (To include State and Municipal Bonds)
5
Salary, Bonus and Commissions
6
IRA Distributions
7
Rental Income (Net)
8
Alimony/Child Support
9
Other Income (Sick Pay, Disability Payments, Gifts, etc.)
10 Total Gross Income For Each Person
$
$
11 Total Gross Income for Applicant & Spouse
$
ALL OTHER OWNERS AND RELATIVES RESIDING IN THE PROPERTY
Other Owner
Other Owner
/Relative 1
/Relative 2
12 Social Security or Railroad Retirement
13 Pension
14 Annuity
15 Interest and Dividends (To include State and Municipal Bonds)
16 Salary, Bonus and Commissions
17 IRA Distributions
18 Rental Income (Net)
19 Alimony/Child Support
20 Other Income (Sick Pay, Disability Payments, Gifts, etc.)
21 Total Gross Income For Each Person
$
$
22 Total Gross Income for Relative(s), Other Owner(s)
$
OFFICIAL USE ONLY
Total Income for Personal Property Tax Relief (Line 11)
$
Total Gross Income for Real Estate Tax Relief (Line 11 + Line 22)
$
Less Disability Exclusion
Less Income Exclusion (for Other Relative)
Total Net Income for Real Estate Tax Relief
$
Application Page 2 of 4

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