Form Rp-467-Rnw - Renewal Application For Partial Tax Exemption For Real Property Of Senior Citizens Page 2
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2Page 2 of 2 RP-467-RNW (7/16)
Name of spouse(s) if not owner of property
Source of income of spouse(s)
Amount of income of
spouse(s)
Total income of spouse(s) ..............................................................................................................
Total income of owner(s) and spouse(s) ...............................................................................
a
b Of the income in line a, how much, if any, was used to pay for an owner’s care in a
residential health care facility? Attach proof of amount paid; enter 0 if not applicable.
.......................................................................................................................
b
(see instructions)
c Line a minus line b ..................................................................................................................
c
d 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; ..............................................................................
(i)
(ii) Subtract amount of (i) paid or reimbursed by insurance ................................................
(ii)
(iii) Unreimbursed amount of (i) (attach proof of expenses and reimbursement,
if any; enter 0 if option not available); ............................................................................
(iii)
Subtotal income of owner(s) and spouse(s) (line c minus line d, item (iii)) ............................
e If a deduction for veteran’s disability compensation is authorized by any of the municipalities
in which the property is located, complete the following:
e
Veteran’s disability compensation received. Attach proof; enter 0 if not applicable .......
Total income of owner(s) and spouse(s) (line d subtotal minus line e) ...................................
5 Certification
I (we) certify that all statements made on this application are true and correct to the best of my (our) belief. I (we) 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 number
Date
(If more than one owner, all must sign)
This Area for Assessor’s Use Only
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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