Form Pt 38 - Assessment Freeze For The Elderly And Disabled (Sdcl 10-6a) Page 3
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3INFORMATION FOR ASSESSMENT FREEZE FOR ELDERLY AND DISABLED – 2012 APPLICATION
1. Personal Information
________________________________
____________________________
_____________
Last Name
First Name
Social Security Number
__________________________________________________________________________
Mailing Address
County
Telephone
_________________________________________(month)_____(day)___(year)_____
City
State
Zip Code
Birth Date
=============================================================================
2. Income Calculation – Attach a copy of your completed 2011 Federal Income Tax Return
=============================================================================
Did you file a 2011 Income Tax Return? (circle one)
YES
NO
If yes - - attach a copy of the return
Federal Adjusted Gross Income
$ _________________
Excluded interest not $________________
yet listed
Wages, salaries, tips, other
$ _________________
Alimony payments not $________________
employee compensation
yet listed
Interest
$ _________________
Dividends
$ _________________
Support Payments
$ _______________
Self-employment (explain)
$ _________________
Cash Public Asst.
$ _______________
& Relief
Social Security (attach a copy of
$__________________
Capitol Gains exc
$ _______________
Each household member SSA-1099
From adj. gross income
Medicare premiums
$ __________________
Workers Comp
$ ________________
Title 19, 20 or SSI
$ __________________
Loss of time
$ ________________
insurance
Veterans Disability Pensions
$ __________________
Interest & dividend
$ ________________
Left to accum. except on insurance policies
Railroad retirement benefits
$ __________________
Foster Care Income $ ________________
IRA Disbursements
$ __________________
Life Insurance
$ ________________
Proceeds that exceeds $20,000
Gift or Inheritance that
$ _________________
Other Income
$ ________________
exceeds $500
Gross Amount of any Pensions
0.00
and annuities
$ __________________
TOTAL INCOME
$________________
(Attach all documents of income)
PRINT FOR MAILING
CLEAR FORM
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