Form RP-467:11/09:Application for Partial Tax Exemption for Real

RP-467 (11/09)
NEW YORK STATE DEPARTMENT OF TAXATION & FINANCE
OFFICE OF REAL PROPERTY TAX SERVICES
APPLICATION FOR PARTIAL TAX EXEMPTION FOR REAL PROPERTY OF
SENIOR CITIZENS (AND FOR ENHANCED SCHOOL TAX RELIEF (STAR) EXEMPTION)
NOTE: General information and instructions for completing this form are contained in RP-467-Ins
Persons who qualify for the senior citizens exemption are also deemed eligible for the enhanced school tax relief
(STAR) exemption. No separate application for the STAR exemption (RP-425) need be filed unless the assessor
cannot determine eligibility for enhanced STAR based on this application. Application must be filed with your
local assessor by taxable status date. Do not file this form with the Office of Real Property Tax Services.
l. Name and telephone no. of owner(s)
2. Mailing address of owner(s)
____________________________________
______________________________________
____________________________________
______________________________________
Day No. (
) ______________________
______________________________________
Evening No. (
)____________________
______________________________________
E-mail address (optional) ____________________________________________________________
3. Location of property (see instructions)
___________________________________________
Street address
___________________________________________
City/Town
________________________________________
Village (if any)
________________________________________
School District
Property identification (see tax bill or assessment roll)
Tax map number or section/block/lot___________________________________________________
4. Indicate documents submitted with application as proof of age of owners (See instruction #4):
Birth certificate
Baptismal certificate
Other (specify) ________________________
5. Date applicant(s) acquired ownership of property (see instruction #5): ________________________
6. Indicate document submitted with application as proof of ownership (See instruction #6):
Deed
Mortgage
Other (specify) _____________________________________
7. Do all the owners of the property presently occupy the premises as their legal residence?
Yes
No
If the answer to 7 is NO, is an owner receiving medical care as an in-patient in a residential health
care facility?
Yes
No
If answer is YES, specify name and location of the facility. ________________________________
________________________________________________________________________________
If answer to 7 is NO, is the non-resident owner the spouse or former spouse of the resident owner and
is he or she absent from the residence due to divorce, legal separation or abandonment? Yes
No
If answer is NO, explain. ___________________________________________________________
________________________________________________________________________________
8. Is any portion of the property used for other than residential purposes (commercial, professional
office, etc.)?
Yes
No
If answer is Yes, explain such use and describe the portion that is so used.
RP-467 (11/09)
9.
2
Income of each owner and spouse of each owner for the calendar year immediately preceding date
of application MUST be set forth. (Attach additional sheets if necessary; see instruction #9 for
income to be included.)
Name of owner(s)
Source of income
Name of spouse (s) if
not owner of property
Source of income
of spouse(s)
Subtotal income of owner(s) and spouse (s)
10.
Of the income specified in #9 how much, if any, was used to pay for an
owner’s care in a residential health care facility? (See instruction #10)
(Attach proof of amount paid: enter zero if not applicable.)
Subtotal income of owner(s) and spouse(s) [#9 minus #10]
Amount of income
Amount of income
of spouse(s)
$ ___________________
$ __________________
$ __________________
“Local Option Only”
11.
If a deduction for unreimbursed medical and prescription drug
expenses is authorized by any of the municipalities in which the
property is located (see instructions #11), complete the following:
(a) Medical and prescription drug costs;
(b) Subtract amount of (a) paid or reimbursed by insurance:
(c) Unreimbursed amount of (a) (attach proof of expenses and
reimbursement, if any; enter zero if option not available):
Subtotal income of owner (s) and spouse (s) [#10 minus #11 (c)]
$ __________________
$ __________________
$ __________________
$ __________________
“Local Option Only”
12.
If a deduction for veteran’s disability compensation is authorized
by any of the municipalities in which the property is located
(see instruction #12), complete the following:
Veteran’s disability compensation received (attach proof,
enter zero if not applicable)
Total income of owner(s) and spouse(s) [11(c) minus 12]
$ __________________
$ __________________
RP-467 (11/09)
3
13. Did owner or spouse file a federal or New York State Income Tax return for the preceding year?
Yes
No
(See instruction #13.)
14.
If answer is YES, attach copy of such return or returns.
Does a child (or children), including those of tenants or lessees, reside on the property and attend a
public school, grades K through 12?
Yes
No
If Yes, show name and location of school(s): __________________________________________
_______________________________________________________________________________
If Yes, was the child (or were the children) brought into the residence in whole or in substantial
Yes
No
part for the purpose of attending a particular school within the school district?
I certify that all statements made on this application are true and correct to the best of my belief and I
understand that any willful false statement of material fact will be grounds for disqualification from
further exemption for a period of five years and a fine of not more than $100.
Signature
Marital Status
Phone No.
Date
(If more than one owner, all must sign)
___________________________________
______________
____________________
____________
___________________________________
______________
____________________
____________
___________________________________
______________
____________________
____________
___________________________________
______________
____________________
____________
SPACE BELOW FOR USE OF ASSESSOR
Date application filed ____________________
Proof of age submitted
Proof of ownership submitted
Application approved
Application disapproved
Assessor’s signature
Exemption applies to taxes levied by or for:
Town
County
School
Village
_____%
_____%
_____%
_____%
Date
Clear Form