TM Finance NYC DEPARTMENT OF FINANCE G PROGRAM OPERATIONS DIVISION CRIME VICTIM/GOOD SAMARITAN EXEMPTION APPLICATION Mail to: NYC Department of Finance, P.O. Box 3120, Church Street Station, New York, NY 10008-3120 Instructions: Use this application if you are applying for a partial real property exemption for a disabled crime victim or Good Samaritan who incurred a disability as a result of a crime and has modified a 1-, 2-, 3-family home to accommodate the disability. SECTION I - OWNER INFORMATION 1. Owner #1ʼs Name: a. _____________________________________ b. ___________________________________ FIRST NAME c. Is this Owner #1ʼs primary residence? d. Social Security #: 2. Owner #2ʼs Name: K YES K NO LAST NAME e. Date of Birth: MM DD YY a. _____________________________________ b. ___________________________________ FIRST NAME c. Is this Owner #2ʼs primary residence? d. Social Security #: SECTION II - PROPERTY INFORMATION K YES K NO LAST NAME e. Date of Birth: MM DD YY 1. Address: a. __________ b. _______________________________________ c. _____________ STREET # STREET NAME APT. # 2. Borough: ___________ 3. Block #: __________ 4. Lot #:__________ 5. Zip Code: ___________ SECTION III - ELIGIBILITY INFORMATION Law enforcement officers are not eligible for this exemption. 1. Have any owners listed in Section I, their spouses, children, other family members, or non-family occupants been disabled as a victim of a crime or while trying to prevent or assist during a crime (“Good Samaritan”)? K YES 3. If you checked “YES” to Question 1 and 2, indicate the cost of the improvements made to the property? $_______________ 2. If you checked “YES” to Question 1, have improvements been made to the property to accommodate the personʼs special needs due to the disability? Visit Finance at nyc.gov/finance K YES K NO K NO Crime Victim Ex. Appl. Rev. 08.16.11 American LegalNet, Inc. www.FormsWorkFlow.com Crime Victim/Good Samaritan Exemption Application Page 2 SECTION V - SIGNATURES AND CERTIFICATIONS By signing below, I certify that all statements made on this application and attached schedule(s) are true and correct to the best of my knowledge and that I have made no willful false statements of material fact. I understand that this information is subject to audit, and should Finance determine that I do not qualify for tax exemptions, I will be disqualified from future exemptions and will be responsible for all applicable taxes due, accrued interest, and the maximum penalty allowable by law. All owners must sign and date, whether they reside at the property or not. ___________________________________________________ _________/_________/________ OWNERʼS SIGNATURE DATE ___________________________________________________ _________/_________/________ OWNERʼS SIGNATURE DATE Contact Information: If we have a question about this application, whom should we contact? Contact Name:___________________________________________________________________ Telephone #: _________________________ Email Address:_____________________________ PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR RECORDS. The Department of Finance will inform you of all exemption benefits that you are eligible for on your Statement of Account. American LegalNet, Inc. www.FormsWorkFlow.com