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Disabled Homeowners' Exemption (Dhe) Renewal Application For 2017/18 - New York Department Of Finance Page 4

Disabled Homeowners’ Exemption (DHE) RENEWAL APPLICATION — 2017/18

2. OWNER(S) INFORMATION (CONTINUED)

Owner 1:

NAME (FIRST, LAST)

DATE OF BIRTH (mm/dd/yyyy)

SOCIAL SECURITY / ITIN NUMBER

TELEPHONE

CELL PHONE

(

)

–

(

)

–

NUMBER

IS THIS THE PRIMARY

EMAIL ADDRESS

Yes

RESIDENCE OF OWNER 1?

Owner 2:

NAME (FIRST, LAST)

DATE OF BIRTH (mm/dd/yyyy)

SOCIAL SECURITY / ITIN NUMBER

TELEPHONE

CELL PHONE

(

)

–

(

)

–

NUMBER

EMAIL ADDRESS

IS THIS THE PRIMARY

Yes

RESIDENCE OF OWNER 2?

ARE OWNERS 1 AND 2

Yes

MARRIED TO EACH OTHER?

SIBLINGS (BROTHERS / SISTERS?)

Owner 3:

NAME (FIRST, LAST)

DATE OF BIRTH (mm/dd/yyyy)

SOCIAL SECURITY / ITIN NUMBER

TELEPHONE

CELL PHONE

(

)

–

(

)

–

NUMBER

EMAIL ADDRESS

IS THIS THE PRIMARY

Yes

RESIDENCE OF OWNER 3?

RELATIONSHIP TO OWNERS 1 AND 2

NAME (FIRST, LAST)

TELEPHONE

CELL PHONE

(

)

–

(

)

–

NUMBER

EMAIL ADDRESS

RELATIONSHIP TO OWNERS

The Federal Privacy Act of 1974, as amended, requires agencies requesting Social Security Numbers to inform individuals from whom they seek this information as to whether

compliance with the request is voluntary or mandatory, why the request is being made and how the information will be used. The disclosure of Social Security Numbers for

applicants and income-earning occupants is mandatory and is required by section 11-102.1 of the Administrative Code of the City of New York. Such numbers disclosed on any

reports or returns are requested for tax administration purposes and will be used to facilitate the processing of reports and to establish and maintain a uniform system for identifying

taxpayers who are or may be subject to taxes administered and collected by the Department of Finance. Such numbers may also be disclosed as part of information contained

in the taxpayer’s return to another department, person, agency or entity as may be required by law, or if the applicant or income-earning occupants give written authorization to

the Department of Finance.

8/22/2017

Disabled Homeowners' Exemption (Dhe) Renewal Application For 2017/18 - New York Department Of Finance Page 4

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