Long Form: Property Tax Exemption For Seniors Page 4
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45. Complete this section if applicant or spouse was/is confined to a nursing home, hospital, or
assisted living facility.
5A. Name of Confined Individual
5B. Location
5C. Dates Confined
5D. During confinement, the property was occupied by either a) the spouse of the person confined, b) a financial dependent,
or c) the property remained unoccupied.
True
6. Complete this section if prior residence was condemned in an eminent domain proceeding.
6A. Street address of condemned property
6B. Dates of ownership of condemned property
from:
to:
6C. Dates property was occupied as primary residence
6D. Approximate date of condemnation
from:
to:
6E. Since the condemnation of my prior residence, I have not owned and occupied any property as my primary residence
other than the property for which I am applying for exemption.
True
6F. If condemnation of the prior residence had not occurred, the condemned property would still be my primary residence.
True
7. Complete this section if prior residence was destroyed or otherwise rendered uninhabitable
by a natural disaster.
7A. Street address of destroyed property
7B. Dates of ownership of destroyed property
from:
to:
7C. Dates property was occupied as primary residence
7D. Date property was destroyed by natural disaster
from:
to:
7E. If the destruction of the prior residence had not occurred, the destroyed property would still be my primary residence.
True
8. Complete this section if property is owned by a trust or an individual as trustee.
8A. Name of Trust
8B. Maker(s) of Trust
8C. Trustee(s)
8D. Beneficiary
8D. Beneficiary
8D. Beneficiary (attach additional sheets if necessary)
8E. The property was transferred to the above-named trust solely for estate planning purposes. Had the property not
been transferred, I and/or my spouse would be the owner(s) of record.
True
9. Complete this section if property is owned by a corporate partnership or other legal entity.
9A. Name of Corporate Partnership or Legal Entity
9B. Name of Principal
9B. Name of Principal
9B. Name of Principal (attach additional sheets if necessary)
9C. The property was transferred to the above-named partnership or entity solely for estate planning purposes. Had the
property not been transferred, I and/or my spouse would be the owner(s) of record.
True
10. Affidavit and Signature
I declare, under penalty of perjury in the second degree (§ 18-8-503, C.R.S.), that the information provided on this form and
on any attachments is correct.
Signature:____________________________________________________________
Date:_________________
Signer is:
Applicant
Spouse
Guardian*
Conservator*
Attorney-in-fact*
* Authorization in the form of a court order or power of attorney is required and must be attached to this application.
Other Contact (relative, representative, etc.):______________________________Telephone Number:__________________
You must inform the County Assessor of a change in property ownership or occupancy within 60 days of such change.
Mail, FAX, or deliver this form to your County Assessor by July 15. We recommend you obtain a receipt when delivering
in person, or mailing by certified mail. You may also call the Assessor to verify the application was received.
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