Application For Partial Exemption From Real Estate Taxation For Property Of Physically Disabled Crime Victims 1997
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3Application for Partial Exemption from Real Estate Taxation for Property of Physically Disabled Crime Victims
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SECTION 1 - OWNERSHIP INFORMATION
BOROUGH: ____________________________ BLOCK: ___________________ LOT: _____________
Address of Property: ____________________________________________________________________
Owner(s) name:
Mailing address:
Telephone number:
________________________________
________________________________
________________
________________________________
________________________________
________________
SECTION 2 - PROPER TY / DISABLED OCCUPANT INFORMATION
1a. Is this property a one, two or three family dwelling used solely for
residential purposes? ................................................................................................
YES
NO
1b. Does a disabled person reside in this dwelling ........................................................
YES
NO
1c. Did such person become disabled as the result of being a victim of crime or
being a good samaritan?...........................................................................................
YES
NO
if the answer to any of the three questions above is NO, do not complete remainder of form, as the
property is not eligible for exemption.
2.
Name of disabled person: __________________________________________________________________
3.
Relationship of disabled person to owner: _____________________________________________________
4.
Description of the nature of the disabled person’s physical impairment which substantially limits one or more
life activities: ____________________________________________________________________________
_______________________________________________________________________________________
5.
Description of improvement(s) to the property to accommodate the disabled person: ____________________
_______________________________________________________________________________________
_______________________________________________________________________________________
6.
Explain how the improvement(s) facilitates and accommodates the disabled person’s use and accessibility of
the dwelling: _____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
7.
Date of completion of improvement(s): ________________________
8.
Cost of improvement(s): $___________________________________
CERTIFICATION AND SIGNATURE
I certify that all statements made on this application are true and correct to the best of my belief. I understand that any
willful false statement of material fact will be grounds for disqualification from exemption for a period of five years and a fine.
_______________________________________________________________
____________________________
_______________________________________________________________
____________________________
Signature of Owner(s) (or Owner’s Representative)
Date
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