Form Rp-467-Rnw - Renewal Application For Partial Tax Exemption For Real Property Of Senior Citizens Page 2
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2RP-467-Rnw (9/09)
2
Name of owner(s)
Source of income
Amount of income
_____________________________
_________________________
________________________
_____________________________
_________________________
________________________
_____________________________
_________________________
________________________
Name of spouse(s) if not
Source of income
Amount of
owner of property
of spouse(s)
income of spouse(s)
____________________________
_________________________
________________________
____________________________
_________________________
________________________
____________________________
_________________________
________________________
4.b.
Subtotal of Income of Owner(s) and Spouse(s)
$ _________________
4.c.
Of the income in 4.b., how much, if any, was used to pay for an
owner’s care in a residential health care facility? Please attach proof
$ _________________
of amount paid; enter zero if not applicable
4.d.
[(4.b.) minus(4.c.)]
$ _________________
4.e.
If a deduction for unreimbursed medical and prescription drug
expenses is authorized by any of the municipalities in which property
is located (contact assessor for information), complete the following:
(i) Medical and prescription drug costs;
$ _________________
(ii) Subtract amount of (i) paid or reimbursed by insurance
$ _________________
(iii) Unreimbursed amount of (i) (attach proof of expenses and
reimbursement, if any; enter zero if option not available);
$ _________________
Subtotal income of owner(s) and spouse(s) [4.d. minus 4.e. (iii)]
$ _________________
4.f.
If a deduction for veteran’s disability compensation is authorized by any
of the municipalities in which property is located, complete the following:
Veteran’s disability compensation received (attach proof; enter zero if
not applicable)
$ _________________
Total income of owner(s) and spouse(s) [4.e. minus 4.f.]
$ _________________
5.
Certification
I certify that all statements made on this application are true and correct to the best of my
belief.
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 Renewal Application Filed ___________________
Approved
Disapproved
Exemption applies to Taxes Levied by or for
City/Town ______%
County ______%
School ______%
Village ______%
Assessor’s Signature
Date
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