Form Av-9 - Application For Property Tax Relief - 2017

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Application for Property Tax Relief
AV-9
4
Web
Elderly or Disabled Exclusion (G.S. 105-277.1),
7-16
Disabled Veteran Exclusion (G.S. 105-277.1C), or
PRINT
CLEAR
Circuit Breaker Tax Deferment Program (G.S. 105-277.1B)
County of
, NC
Year 2017
Instructions
Application Deadline: This application must be filed by June 1st to be timely filed. You may submit additional information separately if needed.
Where to Submit Application: Submit this application to the county tax assessor where this property is located. County tax assessor addresses
and telephone numbers can be found online at:
DO NOT submit this application to the North
Carolina Department of Revenue.
- Office Use Only:
Property ID Number
Last Name of Applicant
First Name
Middle Name
Date of Birth
(MM-DD-YY)
Last Name of Spouse
First Name
Middle Name
Date of Birth
(MM-DD-YY)
Residence Address
City
State
Zip Code
Mailing Address (if different from residence address)
City
State
Zip Code
E-mail Address
Home Telephone Number
Work Telephone Number
Ext.
Cell Phone Number
Fill in applicable boxes:
Yes
No
Is this property your permanent legal residence?
Addresses of secondary residences (if any):
Yes
No
If married, does your spouse live with you in the residence? If you answer No, provide your spouse’s address.
Addresses of spouse:
Yes
No
Are you or your spouse (if applicable) currently residing in a health care facility? If you answer Yes, fill in applicable circle
Applicant
Spouse
and indicate current length of stay:
As of January 1, 2017 do you and your spouse (if applicable) own 100% interest in the property? If you answer No, list all
Yes
No
owners and their ownership percentage (round to the nearest 0.1%):
%
%
Owner
Owner
%
%
Owner
Owner
%
%
Owner
Owner
Note: Separate applications are required for each owner that is claiming property tax relief. If husband and wife own the
property, only one application is required.

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