Rp Form 19-53(H) Affordable Rental Housing Application
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2RP FORM 1953h (REV 10/2015)
DEPT. OF FINANCE
County of Hawaii
TAX MAP KEY/ PARCEL ID
ISLE
ZONE
SEC
PLAT
PAR
CPR
Real Property Tax Division
3
Aupuni Center 101 Pauahi Street Suite No. 4 Hilo, Hawai‘i 96720 Fax (808) 961-8415
Appraisers (808) 961-8354 Clerical (808) 961-8201
Collections (808) 961-8282
West Hawai‘i Civic Center • 74-5044 Ane Keohokalole Hwy. Bldg. D, 2nd Flr. Kailua Kona, Hawai‘i 96740
Fax (808) 327-3538 • Appraisers (808) 323-4881 Clerical (808) 323-4880
AFFORDABLE RENTAL HOUSING PROGRAM APPLICATION
THIS APPLICATION MUST BE FILED ANNUALLY, POSTMARKED OR SUBMITTED TO THE REAL PROPERTY TAX DIVISION NO LATER
THAN DECEMBER 31, 2015. BENEFITS OF THIS AFFORDABLE RENTAL HOUSING PROGRAM APPLY TO TAX YEAR 07/01/2016 TO
06/30/2017.
1. LIST ALL OF THE OWNERS HAVING LEGAL INTEREST IN THE PROPERTY:
NAME
ADDRESS
TELEPHONE NUMBER (DAY)
2.
RENTAL PROPERTY ADDRESS:
3.
MONTHLY RENT:
4.
# OF BUILDINGS:
5. # OF BEDROOMS:
6.
TENANT'S CONTACT INFORMATION:
NAME
MAILING ADDRESS
TELEPHONE NUMBER (DAY)
7.
Under penalty and perjury, I certify that the information provided is accurate and that any document submitted with this
application is a true and correct copy. I authorize the County of Hawai'i to verify my rental or any other information on this
application. I further agree to notify the Real Property Tax Division within 30 calendar days if my property is sold or is no
longer being rented or leased at the affordable rental housing rate indicated on this application.
In addition to any penalties, an individual who falsifies and/or misrepresents information to meet the requirements of this
program shall be fined $1,000. This fine shall attach as a paramount lien against the property for which this application is
filed. Retroactive taxes will occur upon sale of the property or if rental exceeds the maximum allowed (SEE SCHEDULE
ON BACK OF FORM) for the year.
By signing, the owner(s) attests that the property being rented will be rented at a rate not to exceed the affordable rental
housing rate for the following calendar year and is legally permitted by all codes.
Signature of Owner
Date
Signature of Owner
Date
Signature of Owner
Date
Signature of Owner
Date
FOR DEPARTMENT USE ONLY
Date Received (
U.S. Postmark
OTC):__________________________ By: ___________________________________________
USPS Extended ZIP: _________________
DUPLEX
PERMITTED
AG
6-MONTH LEASE
_______ PITT
_______ OVR/PITT
CASE NO._______________
Hawai‘i County is an Equal Opportunity Provider and Employer
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