Form 150-490-015 - Property Tax Deferral Application For Disabled Citizens / Senior Citizens

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For Official Use Only
Clear Form
Date received at county
Date received at Revenue
Property Tax Deferral Application
Previous years’ taxes
•
for
O R E G O N
D E PA R T M E N T
Real market value
Disabled Citizens or
Senior Citizens
O F R E V E N U E
•
Read Me
NOTICE:
• Disabled Citizens: You must be determined to be eligible to receive or be receiving federal Social
Security benefits due to disability or blindness on or before April 15 of the year in which the claim is filed.
• Senior Citizens: You must be age 62 or older on or before April 15 of the year in which the claim is filed.
• All New Applicants: You must attach a copy of the recorded deed or contract showing ownership, and
a copy of your property tax statement. Income requirements to qualify and your total household income
(both taxable and nontaxable) for the calendar year prior to this application must be less than $32,500
when applying for 2003. The income requirement may change in later years.
• File your completed application with your county assessor between January 1 and April 15.
APPLICANT SECTION
Type of Applicant
Individual
Husband and wife
Joint ownership
Refiling as surviving spouse
New marriage
(not husband and wife)
Social Security Number
Birth Date Age on April 15 Are you disabled?
Applicant’s Name (last, first, MI)
•
•
•
–
–
Yes
No
Applicant’s Spouse
Social Security Number
Birth Date Age on April 15 Are you disabled?
•
•
–
–
Yes
No
Other joint owner on deed or contract
Social Security Number
Birth Date Age on April 15 Are you disabled?
•
•
–
–
Yes
No
Mailing Address
Property Address (if different than mailing address)
•
City
State
ZIP Code
Telephone Number
(
)
NOW GO TO THE BACK OF THE FORM
COUNTY SECTION
(Do not complete. This section will be completed by the county assessor’s office.)
Model Year
Make
Division of Motor Vehicles ID Number
Serial Number
Mobile
•
Home
Platted
LOT __________________________
BLK ________________________
___________________________ADD
T _____________________
R__________________________
SEC___________________________
Parcel in:
Unplatted
As described in _____________________________ County
Containing ______________________________________ acres
Deed information
Deed recorded in (year) __________________________
Contract recorded in (year) ____________________________
Deed
Document Number
Instrument Number
Microfilm Number
Reel
Book
Page
Assessor’s Account Number
Levy Code
Check
here for
Assessor’s Account Number
Levy Code
split levy
code
Type of residential property described above
Assessor’s
If a multi-family building, or business on the property, give percentage
Certification
•
Single family
Multi-family
of value allocated to the applicant’s unit (percent to be deferred):
______________%
Assessor’s office: attach copies of the tax statement and of the recorded deed or contract.
Assessor’s (or deputy’s) signature verifying applicant is the owner of record
Date
County Number
X
— THIS SPACE FOR DEPARTMENT OF REVENUE USE ONLY —
Approved By (initials)
Date Approved
Denied By (initials)
Date Denied
Application approved
Application denied
150-490-015 (Rev. 12-02)

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