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2004
PROPERTY TAX POSTPONEMENT CLAIM
A
04-05
1. SOCIAL SECURITY NUMBER
2. FIRST NAME
MID. INITIAL
LAST NAME
This Space for
Controller’s Use
Only
3. YOUR DATE OF BIRTH
APN
19_ _
day
year
PLEASE PLACE PREADDRESSED LABEL HERE, IF AVAILABLE
month
4. IN CARE OF NAME (IF APPLICABLE)
County Code
5. MAILING ADDRESS
(NUMBER AND STREET)
6. (CITY)
(STATE)
(ZIP CODE)
Letter Code
7. SOCIAL SECURITY NUMBER OF
DATE OF BIRTH (DOB) OF
NAME OF SPOUSE’ OR
SPOUSE OR DOMETIC PARTNER
SPOUSE OR DOMETIC PARTNER
DOMESTIC PARTNER
Percent No.
8. ADDRESS OF RESIDENTIAL DWELLING
(NUMBER AND STREET)
9. (CITY)
(COUNTY)
(STATE)
(ZIP CODE)
Timely Code
FILING REQUIREMENTS:
Multi Parcel
62 or older
10. If you will be 62 or older on December 31, 2004, check this box.
Income
Blind
11. If you are under 62 on December 31, 2004, and are BLIND
OR DISABLED, check the appropriate box.
Disabled
Proof of disability is required each year.
12. As of Dec. 31, 2003, have you and all other recorded owners, except
spouse and direct-line relatives, owned and occupied as your principal
place of residence the property for which taxes are to be postponed?
YES
NO
TRANSFER
13. Enter the date you purchased your home:
____________
First-time filers, if you purchased your home after December 31, 2003,
STOP. You do not qualify to postpone your property taxes this year.
14. Enter, to the best of your knowledge, the total amount of liens, deeds
of trust, mortgages or other encumbrances recorded against your
home.
$_____________
15. Is your property held in a trust?
YES
NO
16. List name(s) and relationship(s) of all owners of your property. Anyone listed below who
IS NOT a spouse, domestic partner, or direct-line relative must also submit proof of
eligibility.
NAME
RELATIONSHIP
SOCIAL SECURITY NUMBER
DOB