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Disabled Homeowners' Exemption (Dhe) Renewal Application For 2017/18 - New York Department Of Finance Page 2

Renewal Information: Please read but do not submit with your application

2. Owner Information

This section must be completed for all owners of the property (each person on the deed or stock certiﬁcate).

Information for all owners is required even if not all of the owners live on the property.

Indicate if the property is the primary residence for each owner. If the property is not the primary residence for an

owner, or if the owner is absent from the property due to receiving medical care in a health care facility or due to

divorce, legal separation or abandonment, you must submit proof with the application.

– Social Security Numbers or Individual Taxpayer Identiﬁcation Number (ITIN) must be included.

– Indicate the relationship of the owner to other owners of the property.

3. Income Information

Proof of Income

In the box provided on page 3, indicate the Total Combined Income for all owners and spouses,

regardless of where they live, for calendar year 2016. If 2016 income is not available, you can use income for 2015.

(The income of a spouse may be excluded if absent from the residence due to divorce, legal separation or

abandonment.) Please note: This is not your Federal Adjusted Gross Income.

Income Sources

a. All Social Security payments (must

$____________

be full amount received and not the

taxable amount)

b. Dividends

$____________

c. Capital gains

$____________

d. Gains from sales or exchanges

$____________

e. Payments from governmental or

$____________

private retirement or pension plans

f. IRA and Annuity Earnings

$____________

g. Salaries and wages

$____________

(including bonuses)

*Allowable Deductions:

Total Income Sources

$____________

(add lines a–m)

– Unreimbursed medical and prescription drug expenses.

This does not include unpaid expense bills.

*Unreimbursed medical and

If you ﬁled the 1040 Federal Tax Return and completed

–

$____________

prescription drug expenses

a schedule A, we can use the information on the schedule

for paid unreimbursed medical or prescription expenses.

You do not have to send in the receipts.

Total Combined Income

$____________

Total Combined Income does not include:

– IRA distributions

– Supplemental Security Income (SSI)

– Cash Assistance (Public Assistance)

– Gifts, inheritances

– Reverse mortgage proceeds (but any interest

– Return of capital

or dividends realized from the investment of such

– Nazi persecution reparation payments

proceeds are income)

– Federal Foster Grandparent Program payment

4. Certiﬁcation

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

8/22/2017

Disabled Homeowners' Exemption (Dhe) Renewal Application For 2017/18 - New York Department Of Finance Page 2

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