Senior Citizen Property Tax Exemption Application, Third Party Notification For Real Property Taxes Application Forms Page 3

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Senior Citizen Property Tax Exemption Application

Page 6

SECTION 3 - INCOME-PRODUCING PROPERTY

Complete this section if you rent any part of your residence or own income-producing property.

ALL PERSONS FILING A FEDERAL TAX RETURN MUST ATTACH A COPY OF SCHEDULE E, SUPPLEMENTAL INCOME AND LOSS.

1. Is the income-producing property the same as the owner's residence? ........................ q YES

q NO

2. If the answer to 1 is "NO", list the address of the income-producing property: ___________________________

________________________________________________________________________________________

3. Complete the following Income and Expense Statement. Attach a separate Income and Expense Statement for

each rental property. If you attach a copy of your federal Schedule E, IRS form detailing Supplemental Income

and Loss, you do not have to complete the schedule below.

OFFICE USE ONLY

a. GROSS INCOME ........................................... a.

b. EXPENSES FOR ENTIRE BUILDING

Real estate taxes ............................................... _______________________

_____________________

Mortgage interest............................................... _______________________

_____________________

Water and sewer charges .................................. _______________________

_____________________

Heating fuel (if provided to tenants)................... _______________________

_____________________

Electric (if provided to tenants) ......................... _______________________

_____________________

Insurance .......................................................... _______________________

_____________________

Major repairs .................................................... _______________________

_____________________

Painting / cleaning / maintenance ..................... _______________________

_____________________

Other specify :___________________________ _______________________

_____________________

N E T I N C O M E O F P R O P E R T Y

TOTAL EXPENSES .............................................. b.

SECTION 4 - CERTIFICATION BY COOP BOARD OF MANAGERS

For Cooperative properties only - The following information must be completed by an officer of the cooperative corporation:

Applicant's unit number: ___________

Floor number of this unit: ___________

Monthly maintenance charge for this unit: $ ____________________

Number of shares in this unit owned by applicant: ____________ Date applicant purchased these shares: _______ / _______ / _______

Borough: ______________________ Block: ______________ Lot: ____________ of the building in which this unit is located.

Total number of shares for this development: _________________________

I certify that the above information is true and correct.

(

)

____________________________________

________________________________

______________ ________________

Signature of Officer

print name

Title

Telephone number

C E R T I F I C A T I O N a n d S I G N A T U R E

I certify that all statements made on this application are true and correct to the best of my belief. I understand that any willful false statement of

material fact will be grounds for disqualification from future exemption for a period of five years and a fine of not more than $100.

___________________________________

_________________

___________________________________

_________________

___________________________________

_________________

Signatures of all applicants

Non-relative witness

Date

Sen. Cit. Prop. Tax Exempt. Appl. Rev. 09/98