Form Rp-467 - Application For Partial Tax Exemption For Real Property Of Senior Citizens (And For Enhanced School Tax Relief (Star) Exemption) Page 3

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RP-467 (11/09)
3
13. Did owner or spouse file a federal or New York State Income Tax return for the preceding year?
Yes
No
If answer is YES, attach copy of such return or returns.
(See instruction #13.)
14. Does a child (or children), including those of tenants or lessees, reside on the property and attend a
public school, grades K through 12?
Yes
No
If Yes, show name and location of school(s): __________________________________________
_______________________________________________________________________________
If Yes, was the child (or were the children) brought into the residence in whole or in substantial
part for the purpose of attending a particular school within the school district?
Yes
No
I certify that all statements made on this application are true and correct to the best of my belief and I
understand that any willful false statement of material fact will be grounds for disqualification from
further exemption for a period of five years and a fine of not more than $100.
Signature
Marital Status
Phone No.
Date
(If more than one owner, all must sign)
___________________________________ ______________
____________________
____________
___________________________________ ______________
____________________
____________
___________________________________ ______________
____________________
____________
___________________________________ ______________
____________________
____________
SPACE BELOW FOR USE OF ASSESSOR
Date application filed ____________________
Exemption applies to taxes levied by or for:
Proof of age submitted
Town
_____%
Proof of ownership submitted
County
_____%
Application approved
School
_____%
Application disapproved
Village
_____%
Assessor’s signature
Date
Clear Form

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