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Disabled Homeowners' Exemption Prequalifying Checklist & Income Worksheet For 2018/2019 - New York Department Of Finance Page 6

Disabled Homeowners’ Exemption (DHE) INITIAL APPLICATION — 2018/19

4. ADDITIONAL PROPERTIES OWNED (IF ANY) (CONTINUED)

Additional property 2:

BOROUGH

BLOCK

LOT

PARCEL ID

OWNER(S) NAME

STREET ADDRESS

APT

CITY

STATE

ZIP

EXEMPTIONS RECEIVED

Basic STAR/Enhanced STAR

Senior

Disabled

Veterans

Other: _____________

An owner and their spouse cannot have exemptions on more than one property, unless the spouse or former

spouse is absent due to divorce, legal separation or abandonment. In one of those cases, please submit a copy of

court documents.

5. CERTIFICATION

Please read carefully and sign the certification below. Your application is not complete if you do not sign.

I certify that all statements made on this application are true and correct to the best of my knowledge and that I have

made no willful false statements of material fact. I understand that this information is subject to audit and should the

Department of Finance determine that I made false statements, I may lose my future exemptions and be responsible

for all applicable taxes due, accrued interest, and the maximum penalty allowable by law.

All owners must sign and date this application, regardless of where they reside.

PRINT NAME OF OWNER 1

SIGNATURE OF OWNER 1

DATE OF APPLICATION

PRINT NAME OF OWNER 2

SIGNATURE OF OWNER 2

DATE OF APPLICATION

PRINT NAME OF OWNER 3

SIGNATURE OF OWNER 3

DATE OF APPLICATION

DHE Initial Rev. 12/4/2017

Disabled Homeowners' Exemption Prequalifying Checklist & Income Worksheet For 2018/2019 - New York Department Of Finance Page 6