Form Pt 38 - Application For Freeze On Assessments Of Dwellings Of Disabled And Senior Citizens (Sdcl 10-6a)
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SD EForm - 1289
V3
APPLICATION FOR FREEZE ON ASSESSMENTS OF DWELLINGS OF DISABLED AND SENIOR CITIZENS (SDCL 10-6A)
st
REMINDER – Application to be made on an annual basis on or before April 1
======================================================================================================================
1. Personal Information
======================================================================================================================
____________________________________________________________________________________________________________________________________
Last Name
First Name
Social Security Number
____________________________________________________________________________________________________________________________________
Mailing Address
County
Telephone
________________________________________________________________________________________________(month)________(day)_______(year)_______
City
State
Zip Code
Birth Date
Legal description of property for which assessment freeze is to apply: ____________________________________________________________________________
__________________________________________________________________________________________________ Year Became Disabled ______________
======================================================================================================================
2. Income Calculation
======================================================================================================================
Federal Adjusted Gross Income Form 1040, $___________________ PLUS additional income $__________________________ (see below for other income which
is to be included) = TOTAL INCOME $______________
0.00
ATTACH A COPY OF YOUR COMPLETE 2004 FEDERAL INCOME TAX RETURN. IF YOU OR YOUR HOUSEHOLD MEMBERS DID NOT FILE A 2004
INCOME TAX RETURN, LIST YOUR INCOME BELOW:
Wages, salaries, tips, other employee compensation .
$_______________
Alimony payments not yet listed $_________________________
Interest . . . . . . . . . . . . . . . . . . . . . .
$_______________
Worker's Compensation . . . . .
$_________________________
Dividends. . . . . . . . . . . . . . . . . . . . . .
$_______________
Loss of time insurance . . . .
$_________________________
Self-employed (explain). . . . . . . . . . . . . . . .
Support payments. . . . . . .
$_________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cash Public Asst. & Relief . . . . $_________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_______________
Title 19, 20 or SSI . . . . . . . .
$_________________________
Social Security (attach a copy of your SSA-1099
Capitol gains excluded from adjusted gross
income form for each member of the household . . . .
$_______________
on your federal income tax return $_________________________
Medicare Premiums. . . . . . . . . . . . . . . . . .
$_______________
Interest and dividend
Veterans pensions and disability payments. . . . . .
$_______________
left to accumulate
Railroad retirement benefits . . . . . . . . . . . .
$_______________
except on insurance policies . . . $_________________________
Other Pensions and annuities . . . . . . . . . . . . . . . . . . . . . $_______________
Other income . . . . . . . . . .
$_________________________
Excluded interest not yet listed . . . . . . . . . . . . . . . . . . . $_______________
0.00
TOTAL INCOME. . . . . . . . . .
$ _________________________
If you live with others in a single household you must report their income as well as your own. If you are applying as part of a household, please list other members below.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Last Name
First Name & Middle Initial
Age
Relationship
Social Security No.
=============================================================================================================================
3. Eligibility
=====================================================================================================================
A.
Were you 65 on or before January 1, 2005 or disabled at anytime during 2004?
YES
NO
Proof of disability is required each year.
Did you turn 65 or become disabled in or prior to 1981?
YES
NO
(Base year assessment to be frozen - 1977)
B.
Have you owned a single family dwelling for at least one year?
YES
NO
C.
Have you been a resident of South Dakota for at least one year?
YES
NO
D.
Have you lived in your single family dwelling for at least two hundred days
of the previous calendar year?
YES
NO
E.
Do you live alone and have a yearly income under $20,440.00?
YES
NO
OR Do you live in a household whose members' combined income is under $25,550.00?
YES
NO
I have examined this claim and it is correct to the best of my knowledge. I authorize any person holding official
social security records, official public aid records, official veterans administration records or any other records
containing information relative to this claim to disclose the information contained on the records to county
treasurer.
____________________________________________________
__________________________________________________
Claimant's signature
date
Preparer's signature
_________________________________________________
Address
City
_________________________________________________
Telephone Number
PT 38 (06-04)
REMINDER - Application to be made on an annual basis on or before April 1st
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