Senior Citizen Property Tax Exemption Application, Third Party Notification For Real Property Taxes Application Forms Page 4
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4Third Party Notification for Real Property Taxes Application
REQUEST FOR MAILING OF DUPLICATE TAX BILLS
OR STATEMENTS OF UNPAID TAXES TO A THIRD PARTY
I request that a duplicate of any tax bill or statement of unpaid taxes with respect to my property as described
below be mailed to the person whom I have designated.
In making this request, I understand that neither the tax collecting officer nor any other local government
employee has any liability if for any reason the duplicate is not mailed to or not received by my designee.
SECTION 1 - TAXPAYER INFORMATION
The Applicant is (check one):
q
q
Taxpayer Name ______________________________________________
At least 65 years of age
OR
Disabled
Mailing Address ______________________________________________
SECTION 2 - THIRD PARTY DESIGNEE
City & State ___________________________ Zip Code _____________
Third Party Name ____________________________________________
Property Identification (as shown on assessment roll) _____________
Mailing Address _____________________________________________
____________________________________________________________
City & State __________________________ Zip Code ____________
Tax Billing Address (if different than mailing address) _____________
Telephone __________________________________________________
____________________________________________________________
___________________________________
____________________
___________________________________
_____________________
Signature
Date
Signature
Date
SECTION 3 - PHYSICIAN’S CERTIFICATION OF PHYSICAL OR MENTAL DISABILITY
Taxpayer Name: _____________________________________________________________________________________________________________
Office Address: _____________________________________________________________________________________________________________
NYS License Number ____________________________________________________
Date of Issue ___________________________________
Patient’s Name ______________________________________________________________________________________________________________
Patient’s Address ____________________________________________________________________________________________________________
Does patient have a physical or mental impairment which substantially limits one or more
q YES
q NO
major life activities (e.g., walking)? ...........................................................................................
I certify that all statements made in this section are true and correct to the best of my knowledge and professional belief.
______________________________________________________________
____________________________________
Signature of Physician
Date
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