Property Tax Payment Agreement Request - New York City Department Of Finance (Page 4 of 4) in pdf

Property Tax Payment Agreement Request - New York City Department Of Finance Page 4

Exemption Eligibility Checklist

Please fill out parts A and B below. If we think you may be eligible for a senior,

disabled homeowner, or veteran exemption or meet the "Circuit Breaker" credit

or active duty military requirements, we will send an application.

If we approve you for any of these exemptions or verify you meet the "Circuit

Breaker" credit or active military duty requirements, we will remove your prop-

erty from the lien sale.

A. Check ALL of the following statements that apply to you.

My property is a 1- to 3-family house or residential condominium.

I own the property listed below and use it as my primary residence.

One of the owners was born in 1948 or earlier and the total combined in-

come for all owners is less than $37,400.

One of the owners receives disability benefits and the total combined in-

come for all owners is less than $37,400.

One of the owners is active duty military personnel.

One of the owners is a veteran or a Gold Star parent.

I received the New York State Property Tax Credit (the "Circuit Breaker"

credit) for Tax Year 2012.

B. You MUST fill in the following information below:

If you do not fill in items 1 through 6, we will not be able to send you an ex-

emption application. Item 8 is optional. Please print all information.

OWNER’S NAME:_____________________________________________________

PHONE NUMBER: ( _ _ _ ) _ _ _ - _ _ _ _

STREET ADDRESS: ___________________________________________________

CITY: _______________________________________________________________

STATE:_________________________ 6. ZIP CODE: _______________________

BOROUGH: _______________________ BLOCK:

________ LOT: __________

EMAIL ADDRESS:_____________________________________________________

Mail to:

NYC Department of Finance, Lien Sale Exemptions Unit,

59 Maiden Lane, 22nd Floor, New York, NY 10038.

Property Tax Payment Agreement Request - New York City Department Of Finance Page 4