Form Pt 38 - Assessment Freeze For The Elderly And Disabled (Sdcl 10-6a)
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SD EForm - 1289 V12
PT 38 – ASSESSMENT FREEZE FOR THE ELDERLY & DISABLED (SDCL 10-6A)
(ATTACH – INCOME INFORMATION FOR ASSESSMENT FREEZE)
Applicant’s Name
Applicant‘s Mailing Address
_______________________________________________
_______________________________________________
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HOUSEHOLD INFORMATION
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List all others living in the household. If you are applying as part of a multiple member household, you must
include their income as well as your own. Please list other members of the household below.
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Last Name
First Name & Middle Initial
Age
Relationship
Social Security No.
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PROPERTY INFORMATION
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Legal description of property for which assessment freeze is being made:
_______________________________
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ELIGIBILITY
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A. Were you 65 on or before January 1, 2012 or disabled at anytime during 2011?
YES
NO
Proof of disability is required each year. Year became disabled ______________
Did you turn 65 or become disabled in or prior to 1981?
YES
NO
(Base year assessment to be frozen - 1977)
B. Have you owned a single family dwelling for at least one year?
YES
NO
C. Have you been a resident of South Dakota for at least one year?
YES
NO
D. Have you lived in your single family dwelling for at least two hundred days
of the previous calendar year?
YES
NO
E. Do you live alone and have a yearly income under $24,116.03?
YES
NO
OR Do you live in a household whose members'
combined income is under $31,395.04?
YES
NO
I authorize any person holding official social security records, official public aid records, official veteran’s administration
records or any other records containing information relative to this claim to disclose the information contained on the
records to county treasurer.
I hereby state that the above information is correct to the best of my knowledge. I further understand that
submission of falsified information on this form will result in assessment of the tax reduction and it shall be a
lien on the property, and I will be barred from receiving this tax reduction for the following three years.
_____
__________
Claimant's signature
date
Preparer's signature
______
_____
Address
City
___
_________________
PT 38 (12/11)
Telephone Number
st
REMINDER – Application to be made on an annual basis on or before April 1
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