Form Av-9 - Application For Property Tax Relief - 2012 Page 5
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5Page 5,
AV-9, Web, 6-11
Part 6. Affirmation and Signature
AFFIRMATION OF APPLICANT – Under penalties prescribed by law, I hereby affirm that, to the best of my knowledge and belief, all
information furnished by me in connection with this application is true and complete. Furthermore, I understand that if I participate
in the Circuit Breaker Property Tax Deferment Program, liens for the deferred taxes will exist on my property, and that when
a disqualifying event occurs, the taxes for the year of the disqualifying event will be fully taxed and the last three years of
deferred taxes prior to the disqualifying event will become due and payable, with all applicable interest.
Applicant’s Name (please print)
Applicant’s Signature
Date
Spouse’s Name (please print)
Spouse’s Signature
Date
Refer to the Instructions on Page 1 for filing information and filing location.
Office Use Only
Approved: Y / N
Elderly/Disabled
Disabled Veteran
Circuit Breaker:
4%
5%
Date: ___________/________/_________ By: ________________ Comments: _________________________________________________
AV-9A Received: ___________/________/_________ NCDVA-9 Received: ___________/________/_________
FITR Received: ___________/________/__________ Income: $______________________________________
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Parent category: Financial