Form Pt 46b - Application For Paraplegic Property Tax Reduction
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1
2APPLICATION FOR PARAPLEGIC PROPERTY TAX REDUCTION (SDCL 10-4-24.11, 10-4-24.12, 10-4-24.13)
REMINDER: Application must be made on an annual basis
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1. Personal Information
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___________________________________________________________________________________________________________
Last Name
First Name
Social Security Number
Mailing Address
County
Telephone Number
(month)_____ (day) ___ (year) ____
City
State
Zip Code
Birth Date
Parcel Number _______________________________
Legal description of property for which exemption is requested:
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2. Income Calculation
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Federal Adjusted Gross Income $___________________ PLUS additional income $__________________________ (see below for other income which is to
be included) = TOTAL INCOME $______________
ATTACH A COPY OF YOUR COMPLETE 2002 FEDERAL INCOME TAX RETURN IF YOU OR YOUR HOUSEHOLD MEMBERS DID NOT FILE A 2002
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 Assistance & Relief
$ __________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_____________________
Title 19, 20 or SSI . . . . . .
$ __________________
Social Security (attach a copy of your SSA-1099
Capitol gains excluded from
form for each member of the household . . . . . . . . .
$_____________________
adjusted gross income on your
Medicare Premiums. . . . . . . . . . . . . . . . . . . . . . . . . .
$_____________________
federal income tax return . . .
$ __________________
Veterans pensions and disability payments. . . . . . . .
$_____________________
Interest and dividend left to
Railroad retirement benefits . . . . . . . . . . . . . . . . . . .
$_____________________
accumulate except on insurance
Other Pensions and annuities . . . . . . . . . . . . . . . . . .
$_____________________
policies. . . . . . . . . . . .
$ __________________
Excluded interest not yet listed . . . . . . . . . . . . . . . .
$_____________________
Other income. . . . . . . . . .
$ __________________
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.
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3. Eligibility
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A. Are you a paraplegic or an individual with the loss or loss of use of both lower extremities?
YES
NO
B. Is your home specifically designed as a wheel chair home?
YES
NO
C. Did you own and occupy your home during the entire year of 2002?
YES
NO
D. Are you the un-remarried widow or widower of a qualified veteran?
YES
NO
E. Do you live alone and have a yearly income under $8,000?
YES
NO
OR Do you live in a household whose members' combined income is under $12,000?
YES
NO
I have examined this claim and it is correct to the best of my knowledge.
__________________________________________________
_________________________________________________
Claimant's signature
DATE
Preparer's signature
DATE
_________________________________________________
Address
City
_________________________________________________
PT 46B (5-02)
Telephone Number
REMINDER: Application must be made on an annual basis
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