Form 150-490-014 - Property Tax Deferral Application For 61 Or Younger And Disabled Or 62 Or Older - 2012

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2012
For official use only
Date received at county
Date received at Revenue
Property Tax Deferral Application for
2011–12 Net property taxes
•
61 or younger and disabled or
62 or older
2011–12 Real market values
(ORS 311.666-701)
Notice:
• All new applicants: You must attach a copy of your 2011–12 property tax statement. You must complete the
Household Income and Asset Worksheet on the back of this application.
• Individuals with disabilities: You must be de ter mined to be eligible to receive or be receiving federal
Social Security disability ben e fits on or before April 15 of the year in which the claim is filed, attach proof
of your eligibility (we will not accept your 1099 SSA statement or New Benefit statement).
• Remember to sign and date your application.
• File your completed application with the county assessor’s office after January 1 and on or before April 15.
Applicant section
Type of applicant
Individual
Joint
RDP
Refiling as surviving spouse
New marriage
Divorce
Applicant’s name (last, first, MI)
Social Security number
Birth date
Age on April 15 Are you disabled?
•
•
•
–
–
Yes
No
Joint applicant’s name (last, first, MI)
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/message no.
E-mail for program updates/contact
(
)
Model year
Make
Home number
Square footage
# of bedrooms
Man u fac tured
•
Structure
# of bathrooms Roofing material
Siding type
Heating system
Cooling system
(Mobile Home)
How many years have you owned and lived in the home as of April 15, 2012?
If your answer to the above question is less than five years, STOP HERE. You do not qualify for the Deferral Program.
Do you have a reverse mortgage that is secured by this home?
Yes
No
If your answer to the above question is yes, STOP HERE. You do not qualify for the Deferral Program.
Is the home insured for fire and other casualty?
Yes
No
If your answer to the above question is no, STOP HERE. You do not qualify for the Deferral Program.
Insurance carrier
Policy number
Coverage amount
$
(See Delay of
Foreclosure
Do you owe prior years’ property taxes?
Yes
No
➛
NOW GO TO THE WORKSHEET PAGE
application)
150-490-014 (Rev. 12-11)

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