2015 Over 65 Disability Renewal Form printable pdf download

GAYNELL HENDRICKS

TAX ASSESSOR

Tel: (205) 481-4125

ANDREW BENNETT

Fax: (205) 481-4128

ASSISTANT TAX ASSESSOR - BESSEMER DIVISION

1801 3rd Ave North Room 209

BESSEMER, AL 35020

THIS IS THE RENEWAL FORM REQUIRED FOR THE OVER 65 OR DISABILITY EXEMPTION FOR TAX

YEAR 2015. THIS LETTER MUST BE RETURNED TO THE ADDRESS AT THE TOP OF THIS LETTER

BY DECEMBER 31, 2014.

1. Were you the owner and occupant of this property October 1, 2014? Yes___ No___

2. Your Date of Birth: __________________________ Spouse’s Date of Birth: ____________________________

3. Did you or your spouse retire because of a permanent and total disability? Yes_____No______

If you answered 'Yes', who is totally and permanently disabled? You ___________ Spouse ____________

4. Did you and/or your spouse file 2013 Federal Income Tax Returns? Yes ___________ No _______________

If you answered “YES”, enter your Taxable Income from your 2013 Federal Income Tax Returns on Line 43 (Form 1040); line 27

(Form1040 A); or line 6 (Form 1040 EZ):$__________________

5. Did you and/or your spouse file 2013 Alabama State Income Tax Returns? Yes ___________ No _______________

If you answered "Yes", enter your Adjusted Gross Income from your 2013 Alabama Tax Returns as shown on Line 10 (Form 40) or Line

7 (Form 40A):

Total Adjusted Gross Income

$ ___________

What is your portion of the Total Adjusted Income?

$___________

What is your spouse's portion of the Total Adjusted Income?

$___________

(Line b and line c should total Line a.)

Failure to respond to this exemption recertification by Dec 31, 2014 may result in the taxpayer losing their total homestead

exemption for 2015.

I hereby affirm that the information submitted on this form is true and correct to the best of my knowledge and that any

fraudulent statement is subject to a penalty for perjury and shall be ordered to pay twice the amount of any ad valorem

taxes which would have been due retroactive for a period of up to 10 years plus interest.

___________________________________________________________________________________________________

#1 Homeowner's Signature

____________________________________________

Daytime Phone Number _______________________________

Spouse's Signature

2015 Over 65 Disability Renewal Form