Form Dor 82104 - Senior Property Valuation Protection Option - 2015
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SENIOR PROPERTY VALUATION PROTECTION OPTION
INITIAL APPLICATION
YELLOW fields are Read-Only. You can not enter data in yellow fields.
NOTICE OF REAPPLICATION
These fields are calculated as you fill in the form.
APPLICANT: Please read the instructions on the reverse side before completing this form. Complete the form and
copy for your records before submitting it to the County Assessor where your primary residence is located. The form
must be submitted by September 1.
Application Date __________ County ___________________ Book ___________ Map ___________ Parcel __________
Applicant’s Name(s) ________________________________________________________________________________
Primary Residence Address _________________________________________ City ______________ Zip ___________
Years lived in primary residence _________ (must be minimum of two years). Provide proof of residency by submitting utility
statements, voter registration, or other documentation of proof as requested by the Assessor.
NOTE: “Primary residence” is defi ned as that residence which is occupied by the taxpayer for an aggregate of nine months
of the calendar year. A qualifi ed taxpayer can have only one primary residence.
Are you the sole owner? Yes
No
If co-owned, please state total number of owners ___________________
At least one of the owners must be sixty-fi ve years old. Provide proof of age (birth certifi cate, driver’s license, passport, etc.).
Qualifi ed Owner’s date of birth: _______________
INCOME INFORMATION: List total annual income for all owners from all sources, taxable and non taxable, for
the previous three calendar years. Documentation may be requested by the Assessor to verify income.
INCOME FROM ALL SOURCES
Year One _______
Year Two _______
Year Three ______
Salaries, wages, and tips earned.
$
$
$
Social Security benefi ts received.
Pension and annuity income received.
Dividend and interest income received.
Rent and royalty income received.
Business and farm income received.
Unemployment insurance payments received.
Workmen‘s compensation payments received.
Railroad retirement benefi ts received.
Veteran’s disability pension payments received.
Alimony payments received.
Estate and trust income received.
Public Assistance payments received.
Other income earned or received.
TOTAL ANNUAL COMBINED INCOME =
$
$
$
Three Year Total Annual Combined Income $ ___________________ Three Year Average $ _________________
Under penalty of perjury, I hereby certify that all of the information contained in this application form is true and correct.
I consent to the freezing of the full cash value of my primary residence for a three year period.
Print Name _____________________________________________________ Phone ____________________________
Signature __________________________________________________________________ Date __________________
THIS BLOCK IS FOR COUNTY ASSESSOR USE ONLY
Residency/Age/Income Requirements Met? Yes
No
Valuation Freeze Approved Yes
No
Amount of Three Year Average Income Verifi ed $ _____________ Assessor/Deputy _______________ Date __________
Valuation Protection Option applied to valuation years ________, ________ and ________.
DOR 82104 (Revised 11/2015)
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Parent category: Financial