Form Rp-459 - Application For Partial Exemption For Real Property Of People Who Are Physically Disabled Page 2

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RP-459 (1/95)
2
SECTION 2:
1. _____________________________
________________________
__________________
Physician’s name
New York State License no.
Date of Issue
Office address:
2.
3. Patient’s name:
4. Patient’s address:
_________________________________________________________________________
5a. Does patient have a permanent physical impairment which substantially limits one or more major life
activities (e.g. walking)?
Yes
No
b. If yes, description of patient’s permanent physical disability:
6. Explain how improvement to real property facilitates and accommodates patient’s use and
accessibility of property:
I certify that all statements made in this section are true and correct to the best of my knowledge and
professional belief.
__________________________________________
______________________
Signature of physician
Date
Clear Form
SPACE BELOW FOR ASSESSOR’S USE
Date application filed_________________
Application approved
Application disapproved
Applicable taxable status date______________________________
(a) Assessed valuation of parcel including value attributable to improvements made to
facilitate use and accessibility of property by physically disabled person................... $_____________
(b) Assessed valuation of parcel excluding value attributable to improvements made to
facilitate use and accessibility of property by physically disabled person................... $_____________
Assessed valuation of exemption granted [ (a) less (b)] ............................................. $_____________
Exemption applies to taxes levied by or for:______________________________________________
Name of county, city, town, village or school
district granting exemption
_________________________
_____________________________________
Date
Signature of assessor

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