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Exemption Application For Owners Form. This is a New York form and can be use in New York Local County.
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Tags: Exemption Application For Owners, EX-01, New York Local County, New York
NEW YORK CITY DEPARTMENT OF FINANCE
PROGRAM OPERATIONS DIVISION
EXEMPTION APPLICATION FOR OWNERS 2012/2013
TM
Finance
G
INSTRUCTIONS
Owners may be eligible for several exemptions that reduce property taxes. This application can be used for the following exemption programs
for your NYC primary residence: STAR (School Tax Relief, either Basic or Enhanced), Senior Citizen, Veterans, and Disabled. New York State
residents owning property in New York City may use this application for the Clergy Exemption. Please indicate the exemptions for which you
are applying and complete the applicable sections. Detailed instructions on completing the form follow the application. If you have any questions,
please call 311.
Please mail this application with ALL REQUIRED DOCUMENTS to NYC Department of Finance, PO Box 3120, Church Street Station, New
York, NY 10008-3120. Applications must be postmarked by March 15, 2012, to be eligible for the 2012/13 tax year.
FA X E S W I L L N O T B E A C C E P T E D
Please check the box of each exemption you are requesting:
STAR
K
Sections 1, 2, 4 & 8
Enhanced STAR
Senior
K
Sections 1, 2, 3, 4 & 8
Disabled
K
Sections 1, 2, 3, 4 & 8
SECTION 1 - PROPERTY INFORMATION
1. Address
BBL
a. ______________
HOUSE NUMBER
Your propertyʼs BBL can be
found at: nyc.gov/finance
Veteran
STREET NAME
d. ________________________ e. ________________
1-, 2-, 3-family dwelling
K
Condominium Unit
Clergy
K
Sections 1, 2, 6 & 8
b.___________________________________________
BOROUGH
2. Type of Residence (check one):
K
K
K
K
Sections 1, 2, 4, 5 & 8
BLOCK
K
Sections 1, 2, 7 & 8
c. _______________
APARTMENT NUMBER
f. ________________
LOT
Cooperative - Unit # _____________________ and the number of shares: #______________.
Other (please specify): ___________________ and the percent of space used for primary residence:_______%
3. Management Company/
Agent Contact Information: ______________________________________ Phone # ________________________
SECTION 2 - OWNER INFORMATION
If there are more than two owners, please complete the Additional Ownersʼ Sheet.
1. Owner #1: a. _____________________________________
c. Date of Birth:
FIRST NAME
MM
DD
d. Social Security #:
YYYY
b. _______________________________________
LAST NAME
e. Phone: ____________________
f. Email: __________________________________________ g. Is this Owner #1ʼs Primary Residence?
2. Owner #2: a.______________________________________
c. Date of Birth:
FIRST NAME
MM
DD
YYYY
d. Social Security #:
3a. Are owners #1 and #2 spouses, siblings or registered domestic partners?
SECTION 3 - AGE VERIFICATION
I YES
I NO
b. _______________________________________
LAST NAME
e. Phone: ____________________
f. Email: __________________________________________ g. Is this Owner #2ʼs Primary Residence?
3b. Is there a Life Estate on this property?
I YES
I YES
I YES
I NO
I NO
I NO If “YES”, Owner of Life Estate: _______________________________
If you are applying for a Senior Citizen or Enhanced STAR exemption, you MUST provide a copy of a government-issued ID
(e.g., driver's license, passport or birth certificate) for all owners turning 65 by December 31, 2012.
SECTION 4 - INCOME INFORMATION
In order to determine your eligibility for the Basic STAR and Enhanced STAR, Senior Citizen and/or Disabled Homeowner,
please provide the following documents:
REQUIRED: Copies of 2010 Federal tax returns and schedules/attachments for all owners. If any owner was not required to file, please submit
proof of earnings (copies of W-2 forms, Social Security, 1099 forms, etc.) Please write names of owners NOT required to file and the reason why.
EX-01 Rev 10.14.11
1. ________________________________________________ Reason: _________________________________________
2. ________________________________________________ Reason: _________________________________________
Senior Citizen and/or Disabled Homeowners: Please attach documentation of any unreimbursed medical or prescription expenses.
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Exemption Application for Owners
SECTION 5 - DISABILITY INFORMATION
Do any of the owners, their spouse or registered domestic partner receive any disability income, such
as: Social Security Disability Insurance, Supplemental Security Income, Railroad Retirement Disability
Benefits or a Disability Pension?
YES
Page 2
NO
If you checked YES, please submit one of the following REQUIRED documents:
G
Copy of the award letter from the Social Security Administration
G
Copy of the award letter from the Railroad Retirement Board or the U.S. Postal Service
G
Copy of a certificate from the State Commission for the Blind and Visually Handicapped
SECTION 6 - VETERAN INFORMATION
1. Are any of the owners a veteran?
Are any of the owners a spouse or unremarried widow/er of a veteran?
YES
NO If YES, list years of service. Ex: 1965 - 1972
Are any of the owners a registered domestic partner of a veteran?
Are any of the owners a parent of a soldier killed in action?
If you checked YES to any box, please submit the following REQUIRED document for each veteran:
G
Copy of the DD-214 or separation papers
YES
NO
YES
NO
SECTION 7 - CLERGY INFORMATION
YES
NO
If you are not active:
YES
NO
2. Did the veteran serve in a combat zone or theater?
If YES, where did the veteran serve? (provide proof of service)
3. Was the veteran disabled in the line of duty?
If you checked YES, please submit the following REQUIRED document for each veteran:
G
Copy of a letter from the VA documenting the disability rating for each veteran.
1. Are you an active member of the clergy who is primarily responsible for ministerial work?
2. Were you unable to perform such work due to an illness or impairment?
3. Are you over age 70?
4. Are you the surviving unremarried spouse of the clergy member?
If you checked YES to any box, submit the following REQUIRED document for each clergy member:
verification letter from the church employer
In addition, the following documentation is required:
G
Physicianʼs statement. (If you checked yes to box 2)
G
Copy of a government-issued ID, birth certificate or baptismal certificate. (If you checked yes to box 3)
G
Copy of your marriage certificate and a copy of your spouseʼs death certificate. (If you checked yes to box 4)
G
SECTION 8 - SIGNATURES - CERTIFICATION
By signing below, I certify that all statements made on this application 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 subjected to audit and should Finance determine that I do not qualify for tax exemption, 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 THIS APPLICATION, WHETHER THEY RESIDE ON THE PROPERTY OR NOT
If there are more than two owners, please complete the Additional Ownersʼ Sheet.
___________________________________________________
OWNER
#1 SIGNATURE
___________________________________________________
OWNER
#2 SIGNATURE
_________________________
DATE
_________________________
DATE
* PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR RECORDS *
The Department will inform you of all exemptions benefits that you are eligible for on your Statement of Account.
PRIVACY ACT NOTIFICATION
Under the Federal Privacy Act of 1974, if we ask you to give us your social security number, we must tell you whether or not you are obligated to provide us with the social security number, our
legal right to ask you for the information, and how we plan to use it. You must list you taxpayer identification number (SSN or EIN) in order to apply for an exemption from real property taxes.
We are asking this information to make sure that out records are accurate, and that you have submitted accurate information. Our legal right to require this information is contained in Section
1-102.1 of the Administrative Code. This authorizes the Department of Finance to require any person to provide taxpayer identification number so that we may administer and collect taxes.
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NEW YORK CITY DEPARTMENT OF FINANCE
TM
Finance
PROGRAM OPERATIONS DIVISION
EXEMPTION APPLICATION FOR OWNERS 2012/2013
G
ADDITIONAL OWNERS INFORMATION AND CERTIFICATION
INSTRUCTIONS: If the property is owned by more than two owners, please complete the additional ownerʼs
information below, sign and date and mail this sheet along with your completed application.
ADDITIONAL OWNER(S) INFORMATION
If there are more than 6 owners, please copy this sheet and complete as required.
Owner #3:
c. Date of Birth:
a._____________________________________
FIRST NAME
MM
DD
YYYY
d. Social Security #:
b. _______________________________________
LAST NAME
e. Phone: ____________________
f. Email: __________________________________________ g. Is this Owner #3ʼs Primary Residence?
I YES
I NO
h. Relationship to other owners: _______________________________________________________________________________
Owner #4:
c. Date of Birth:
a._____________________________________
FIRST NAME
MM
DD
YYYY
d. Social Security #:
b. _______________________________________
LAST NAME
e. Phone: ____________________
f. Email: __________________________________________ g. Is this Owner #4ʼs Primary Residence?
I YES
I NO
h. Relationship to other owners: _______________________________________________________________________________
Owner #5:
c. Date of Birth:
a._____________________________________
FIRST NAME
MM
DD
YYYY
d. Social Security #:
b. _______________________________________
LAST NAME
e. Phone: ____________________
f. Email: __________________________________________ g. Is this Owner #5ʼs Primary Residence?
I YES
I NO
h. Relationship to other owners: _______________________________________________________________________________
Owner #6:
c. Date of Birth:
a._____________________________________
FIRST NAME
MM
DD
YYYY
d. Social Security #:
b. _______________________________________
LAST NAME
e. Phone: ____________________
f. Email: __________________________________________ g. Is this Owner #6ʼs Primary Residence?
I YES
I NO
h. Relationship to other owners: _______________________________________________________________________________
ADDITIONAL OWNER(S) SIGNATURES - CERTIFICATION
ALL OWNERS MUST SIGN AND DATE THIS APPLICATION, WHETHER THEY RESIDE ON THE PROPERTY OR NOT
By signing below, I certify that all statements made on this application 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 subjected to audit
and should Finance determine that I do not qualify for tax exemption, 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.
___________________________________________________
OWNER
#3 SIGNATURE
OWNER
#4 SIGNATURE
___________________________________________________
___________________________________________________
OWNER
#5 SIGNATURE
___________________________________________________
OWNER
#6 SIGNATURE
_________________________
DATE
_________________________
DATE
_________________________
DATE
_________________________
DATE
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EXEMPTION APPLICATION FOR TAX YEAR 2012/2013
REQUIRED DOCUMENTS CHECKLIST
Find the exemption(s) you are applying for and follow down the column to see what required documents you must submit with this application. When you see a YES, you MUST submit.
REQUIRED DOCUMENTS
PROOF OF AGE
Copy of a Government-issued ID
(ex: Driverʼs License or Passport).
Enhanced
STAR
YES
Basic
STAR
Senior
Citizen
Home
Owner
(SCHE)
YES
YES
YES
YES
YES
YES
Disabled
Home
Owner
(DHE)
Veteran
Clergy
PROOF OF INCOME
Copies of Federal tax returns and schedules/attachments for 2010 Tax Year for all owners, OR
Indicate on application the names of owners
NOT required to file and the reason why.
PROOF OF DEDUCTIONS
Copies of receipts for unreimbursed medical or
prescription expenses
YES
PROOF OF DISABILITY
One (1) of the following for an owner:
• Copy of the award letter from the Social Security Administration
• Copy of the award letter from the Railroad
Board or the U.S. Postal Service
• Copy of a certificate from the State Commission for the Blind and Visually Handicapped.
PROOF OF BASIC VETERAN
YES
• Copy of DD-214 or separation papers for
each veteran
YES
• Copy of Proof of Service for each veteran
YES
• For each disabled veteran, copy of Veteranʼs Ad-
YES
PROOF OF COMBAT VETERAN
PROOF OF DISABLED VETERAN
ministration letter documenting the disability rating
PROOF OF CLERGY MEMBER
• Copy of verification letter from church employer
If inactive one of the following in addition to the above:
• Physicianʼs statement
• Copy of a government-issued ID
• Copy of Marriage Certificate and
a copy of your spouseʼs death certificate
YES
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TM
Finance
NYC DEPARTMENT OF FINANCE
G
PROGRAM OPERATIONS DIVISION
INSTRUCTIONS FOR
E X E M P T I O N A P P L I C AT I O N F O R O W N E R S
Mail to: NYC Department of Finance, P.O. Box 3120, Church Street Station, New York, NY 10008-3120
OVERVIEW
Finance will review the information and documentation provided in this application to determine your eligibility and, if eligible, or level
of exemption for the following homeowner
tax exemption programs:
I
I
I
I
I
School Tax Relief (STAR) Basic and Enhanced
Senior Citizen Homeownersʼ Exemption
(SCHE)
Veteransʼ Exemption
Disabled Homeownersʼ Exemption (DHE)
Clergy Exemption
To be eligible for any of these programs,
complete this application for your primary
residence, that is, the house, condominium,
or cooperative apartment that you live in for
the majority of the year or the address where
you are registered to vote.
Clergy exemption note: A member of the
clergy does not have to occupy the New York
City property to be eligible for the clergy exemption, but must be a resident of New York
State.
APPLICATION DEADLINE
Finance will accept applications throughout
the year. However, the start date for exemption benefits varies according to when you
apply. If your application is postmarked by
March 15th, benefits will begin July 1st of
the same year. If your application is postmarked after March 15th, benefits will begin
July 1st of the following year.
SPECIFIC INSTRUCTIONS
Please indicate which exemptions you are applying for
by checking the appropriate box(es) and completing
the required sections.
SECTION 1 – PROPERTY INFORMATION
Give the complete address and the borough, block and
lot of the property for which you are seeking tax benefits
and the date you purchased the property. The Borough,
Block and Lot numbers for properties other than coops
can be found on your Statement of Account (tax bill) and
the Finance website at nyc.gov/finance.
Please indicate the type of residence by checking the appropriate box. If the property is a co-op please provide
the Unit #, the number of shares and the name and contact number of the management company/agent.
If you checked “other,” please provide the percentage
of space used as your primary residence.
SECTION 2 – OWNER INFORMATION
Provide the name, social security number and date of
birth of each owner of the property (i.e., each person
named on the deed or proprietary lease, or the owner
of the life estate), whether or not the owner resides at
the property. For purposes of this application, if you
own a life estate in the property, then you are considered the owner of the property and the owner information required to complete this application refers to
information concerning the life estate owners. Social
Security numbers must be included or Finance can not
process your application. If there are more than two
owners, use the Additional Owners Information and
Certification form, which is part of this application
packet.
Indicate if any of the owners listed in Section I are
spouses, siblings or registered domestic partners by
checking the appropriate box.
SECTION 3 – AGE VERIFICATION
If you are applying for a Senior Citizen Homeowners
Exemption or Enhanced STAR, you MUST provide a
copy of a government-issued ID (e.g., drivers license,
passport or birth certificate). To be eligible, you or your
spouse/sibling/domestic partner must turn 65 by
12/31/12.
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Instructions for Exemption Application for Owners
SECTION 4 – INCOME INFORMATION
If you are applying for the Basic STAR, Enhanced
STAR, Senior Citizens and/or the Disabled Homeowners exemption, you MUST provide proof of income for calendar year 2010 for all owners.
If you file a Federal Income Tax return, you MUST
attach a complete copy of your 2010 return including
all schedules and attachments for all owners. If any
of the owners are not required to file a tax return, you
MUST indicate their name(s), the reason they are not
required to file and attach copies of any income documentation such as Social Security Benefits statements or 1099 forms.
If you are applying for a Senior Citizen or Disabled
Homeowners exemption, we will deduct any reimbursed medical or prescription expenses from income to determine eligibility. However, you MUST
attach documentation for any such expenses.
Income Thresholds
Basic STAR - Total combined HOUSEHOLD income
of $500,000 or less.
Enhanced STAR - Total combined HOUSEHOLD income of $79,050 or less.
(Household income is defined as the Federal AGI
less the taxable amount of IRA distributions for all
household members.)
Senior Citizens and Disabled Homeowners - Total
combined income for all the owners of less than
$37,400.
(Refer to the following list for items to be included in
determining income eligibility for SCHE and DHE and
the allowable deductions.)
Income includes:
I
I
I
I
I
I
I
I
All social security payments
Salaries and wages (including bonuses)
Interest (including nontaxable interest on state or
local bonds)
Ordinary dividends
Net earnings from farming, rentals, business or
profession (including amounts claimed as depreciation for income tax purposes)
Income from estates or trusts
Gains from sales and exchanges
Payments from governmental or private retirement or pension plans
I
I
I
Page 2
Annuity payments (excluding amounts representing a return of capital)
Alimony or support money
Unemployment insurance payments, disability
payments, workersʼ compensation, etc.
Income does NOT include:
I
I
I
I
I
I
Supplemental security income
Nazi persecution reparation payments
Federal Foster Grandparent Program payments
Welfare payments
Reverse mortgage proceeds (but any interest or
dividends realized from the investment of such
proceeds are income)
Gifts, inheritances or a return of capital
Allowable deductions:
I
Unreimbursed medical and prescription drug expenses.
SECTION 5 – DISABILITY INFORMATION
Indicate whether any owner receives any of the following forms of disability-related financial assistance: (1)
Social Security Disability Insurance (SSDI); (2) Supplemental Security Income (SSI) benefits; (3) Railroad
Retirement Disability Benefits (RRDB); (4) Disability
pension from the US Postal Service; or has a certificate
from the State Commission for the Blind and Visually
Handicapped stating that he/she is legally blind.
If you checked YES, you MUST submit one of the
following required documents:
I
I
I
Copy of the award letter from Social Security Administration
Copy of the award letter from the Railroad Board
or U.S. Postal Service
Copy of certificate from the State Commission for
the Blind or Visually Handicapped
SECTION 6 – VETERAN INFORMATION
1. Indicate by checking the appropriate box if any of
the owners listed in Section I are veterans, or
spouses, registered domestic partners, unremarried widows, widowers of veterans, or if they are
parents of a soldier killed in action.
“Veterans” are former members of the United
States armed forces or the Merchant Marines (during World War II) or recipients of expeditionary
medals.
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Instructions for Exemption Application for Owners
Periods of conflict are:
I
I
I
I
I
World War I
April 6, 1917 - November 11, 1918
World War II
December 7, 1941 - December 31,1946
Korean Conflict
June 27, 1950 - January 31,1955
Vietnam War
February 28,1961 - May 7, 1975
Persian Gulf War
Beginning August 2, 1990
If you checked YES to any of the boxes and
served during one of the periods of conflict, you
MUST submit a copy of the DD-214 or separation
papers for each veteran.
2. “Combat zone” refers to a location of active combat, such as Vietnam during the Vietnam War.
Veterans who served during a period of conflict but
who were stationed in non-combat areas (for example, a soldier who was in the service during the
Vietnam War dates but who was not stationed in
Vietnam) should check “No.”
If you checked YES, you MUST indicate the combat zone in which you served.
3. For the purpose of this question, “disabled” refers
to a Veteransʼ Administration designation.
If you checked YES, you MUST submit a copy of
a Veterans Administration letter for each veteran
documenting the disability rating.
You can obtain your disability rating from the US
Department of Veterans Affairs by calling 1-800827-1000.
SECTION 7 – CLERGY INFORMATION
A member of the clergy is defined as belonging to
any religious denomination. The clergy member must
(1) perform work assigned by the denomination to
which he/she belongs, as their principal occupation;
(2) be unable to perform such work due to illness or
impairment; or (3) be over the age of 70.
If the member of the clergy is deceased, the surviving
spouse or registered domestic partner may be eligible for a tax reduction for the house the couple
shared, as long as the spouse has not remarried.
Page 3
If you checked yes to any of the boxes, you MUST submit a letter of reference from the church employer.
In addition, if the clergy member is inactive or deceased,
you MUST also submit one of the following:
I
I
I
Physicianʼs statement
Copy of a government-issued ID
Copy of your marriage certificate and a copy of
your spouseʼs death certificate.
SECTION 8 – SIGNATURES AND CERTIFICATIONS
All owners MUST sign and date the application
whether or not they reside at the property.
IMPORTANT
BEFORE MAILING YOUR APPLICATION,
PLEASE REVIEW THE REQUIRED
DOCUMENTS CHECKLIST TO MAKE
SURE THAT YOU HAVE ATTACHED
COPIES OF THE REQUIRED
DOCUMENTATION.
FAILURE TO DO SO WILL DELAY
THE PROCESSING OF YOUR
APPLICATION.
Mail Your Application to:
NYC Department of Finance
P.O. Box 3120
Church Street Station
New York, NY 10008-3120
FAXES WILL NOT BE ACCEPTED.
KEEP A COPY OF YOUR COMPLETED
APPLICATION FOR YOUR RECORDS.
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