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Disabled Crime Victim/good Samaritan Exemption Application - New York Department Of Finance Page 2

Disabled Crime Victim Exemption Application

Page 2

SECTION II - PROPERTY INFORMATION

1. Address: a. __________ b. _______________________________________ c. _____________

. #

STREET

STREET NAME

APT

2. Borough: ___________ 3. Block #: __________ 4. Lot #: _________ 5. Zip Code: ___________

SECTION III - ELIGIBILITY INFORMATION

Law enforcement officers are not eligible for this exemption.

1. Have any owners listed in Section I, their spouses, children, other family

members, or non-family occupants been disabled as a victim of a crime

YES

or while trying to prevent or assist during a crime (“Good Samaritan”)?

Date of crime: _________/_________/__________

2. If you checked “YES” to Question 1, have improvements been made to the

YES

property to accommodate the person’s special needs due to the disability?

Date (month/year) of improvements: _________/_________

3. If you checked “YES” to Question 1 and 2, indicate the cost of the

improvements made to the property.

$_______________

Please provide a police report, a report from the Office of Victim Services, or other documentation

showing that a physical disability was inflicted as a result of a crime.

SECTION IV - SIGNATURES AND CERTIFICATIONS

By signing below, I certify that all statements made on this application and attached schedule(s) are

true and correct to the best of my knowledge and that I have made no willful false statements of mate-

rial fact. I understand that this information is subject to audit, and should Finance determine that I do

not qualify for tax exemptions, I will be disqualified from future exemptions and will be responsible for

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

All owners must sign and date, whether they reside at the property or not.

___________________________________________________ _________/_________/________

’

OWNER

S SIGNATURE

DATE

___________________________________________________ _________/_________/________

’

OWNER

S SIGNATURE

DATE

Contact Information:

If we have a question about this application, whom should we contact?

Contact Name:___________________________________________________________________

Telephone #: _________________________ Email Address:_____________________________

PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR RECORDS.

Disabled Crime Victim/good Samaritan Exemption Application - New York Department Of Finance Page 2

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