Real Estate Tax Relief For Elderly And/or Totally Disabled Persons Application - City Of Alexandria - 2005 Page 3
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1
2
3
4NET COMBINED FINANCIAL WORTH AS OF 12/31/04
(NOT INCLUDING PRINCIPLE RESIDENCE AND LOT UP TO TWO ACRES)
Other
Other
List of Assets
Applicant Spouse
Owner 1
Owner 2
Cash on Hand
Checking Accounts
Savings Accounts
Savings Certificates (CD’s)
Mortgages or Trust Notes Due Me
IRA, 401K or Other Retirement Accounts
Stocks, Bonds and/or Mutual Funds
Life Insurance (Cash Value Of)
Annuity (Cash Value of)
Other Real Estate Owned
Total
Automobile(s) Value
Assessed Value of
Check Block
Qualified Vehicle
for Personal
Assessed Value of
Prop. Relief
Qualified Vehicle
Add Total Assets for All Columns to Arrive at Net Combined Financial Worth: $
Are you required to file a Federal Income Tax Return for 2004?
YES
NO
PLEASE NOTE:
•
Please attach a photocopy of your 2004 return to this application if you are required to
file a federal income tax return: if not available by the time of the filing of this affidavit,
you must submit it by April 20, 2005.
•
All applicants must also attach photocopies of supporting documents that will verify all
sources of income. i.e., Social Security or Railroad Retirement 1099 statement, etc.
•
Failure to submit all financial documentation by the due date will jeopardize your
application.
DECLARATION
I declare under the penalties provided by law that this affidavit, financial statement and any accompanying
schedules, have been examined by me and to the best of my knowledge and belief are true, correct, and
complete. (Any person or persons falsely claiming an exemption shall be guilty of a misdemeanor.)
ANY
PERSON SIGNING FOR AN APPLICANT UNABLE TO SIGN FOR HIMSELF/HERSELF, MUST SIGN
THE APPLICANT’S NAME AND PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF
THE PERSON ASSISTING THE APPLICANT (Signee)*
Your Signature
Date
Spouse’s Signature
Date
(Signee Name)*
Date
Address
Telephone #
Application Page 3 of 4
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