Tax Year 2015 Property Tax Assistance Application Form Page 2
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2Part III. Affirmation and Signature(s)
Under penalty of law, I/we affirm that I/we are owners of the property on which we are applying for the property tax
benefit, that I/we occupied the property as my/our primary residence for at least seven months during the preceding
calendar year and that the information provided in this application form is true and correct.
This completed affirmation, including social security numbers, must be returned with the appropriate
income documentation or your application may be denied.
Signature
Social Security Number
Income
Filing an
Documentation Income Tax
Provided
Extension
q
q
___________________________________________
______ - ____- _______
___________________________________________
______ - ____- _______
q
q
q
q
___________________________________________
______ - ____- _______
___________________________________________
______ - ____- _______
q
q
Contact Phone Number ____________________________________________
(We may need to contact you if we have questions regarding your application.)
Part IV. Head of Household Information (To be completed by the applicant if filing as head of household.)
Name of Dependent
Social Security Number
____________________________________________________
______ - ____- _______
____________________________________________________
______ - ____- _______
____________________________________________________
______ - ____- _______
____________________________________________________
______ - ____- _______
Part V. For Department Use Only
Geocode: _____________________________
School District: _________________________
Assessment Code: ______________________
Granted: q Yes
q No
Applicants Income
Class Codes
Percent
Multiple
Reduction
Single
or
Land
Imp
Mob
Head of Household
$
0 - $8,413 $
0 - $11,217
80
2132 3137 6237
$ 8,414 - $12,900 $ 11,218 - $19,630
50
2135 3140 6240
$ 12,901 - $21,032 $ 19,631 - $28,043
30
2137 3142 6242
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