Form Rp-496 - Application To Renounce Previously-Granted Exemption(S) - Ny State Department Of Taxation And Finance - 2011

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RP-496 (6/11)
NEW YORK STATE DEPARTMENT OF TAXATION & FINANCE
OFFICE OF REAL PROPERTY TAX SERVICES
APPLICATION TO RENOUNCE PREVIOUSLY-GRANTED EXEMPTION(S)
Part I: To be completed by applicant and filed with County Director of Real Property Tax Services.
1. Name and telephone no. of owner(s)
2. Mailing address of owner(s)
Day No. (
)
Evening No. (
)
E-mail address (optional)
3. Location of property
Street address
City/Town
Village (if any)
School District
4. Property identification (see tax bill or assessment roll)
Tax map number or section/block/lot:
5. Exemption(s) being renounced:
6. I am voluntarily renouncing the exemption(s) described above on and after the following date:
_________________ (e.g., if the property is no longer your primary residence, enter the date on
which your primary residence changed.)
Signature
Date
Signature
Date
Part II: For use by COUNTY DIRECTOR:
The amount that must be paid in connection with this renunciation request is:
Sum of the Subtotals on Form(s) RP-496-Wkst (Attach Form(s)):
$
Processing fee:
$
500.00
Total Due:
$
Part III: For use by COUNTY TREASURER:
Amount paid by Applicant
Date of Payment Receipt
Amounts distributed to: Town/City: $
; School:$
; Village:$
;
Special District(s):
(Give name and $ for each, e.g., District A, $300; District B, $250; and so on)
; State (STAR only): $
Clear Form

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