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2. Internet browser preference

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4. Parcel Number *
   PIN, Tax ID, Property Identification Number Your PIN is listed on your property tax bill
5. Assessment Year*
   -- Select One --20222023

   The assessment year for which you are requesting the senior citizens homestead exemption.

7. Date of Birth*
8. Please submit a copy of your driver's license for proof of age
9. Assessor verified:

   1. Yes
   2. No
10. Assessor Initials
12. First Name*
13. Last Name*
15. Address*
17. City*
18. State*
19. Zip Code*
21. Phone Number*
22. Fax Number
24. Email Address*
26. Marital Status*

    1. Single, widow(er), or divorced
    2. Married and living together
    3. Married, but not living together
27. If married, spouses date of birth
29. Spouse's Name
30. Spouse's Last Name
32. Spouse's Address if not living together
34. City
35. State
36. Zip Code
38. Have you previously received a senior citizens homestead exemption on this property?*

    1. Yes
    2. No
42. Check your type of residence*

    1. Single-family dwelling
    2. Townhome
    3. Apartment
    4. Duplex
    5. Condominium
    6. Other
43. Is the residence operated as a cooperative?

    1. Yes
    2. No
44. Is the residence a life care facility under the Life Care Facilities Act?

    1. Yes
    2. No
46. On January 1 were you the owner of record or did you have a legal or equitable interest in this property or did you have a life care contract with a facility under the Life Care Facilities Act? *

    1. Yes
    2. No
47. If No, write the date you acquired an interest in this property
49. On January 1 did you occupy this property as your principal residence?*

    1. Yes
    2. No
50. If No, write the date you first occupied this property. (if applicable)
52. On January 1 were you a resident of a facility licensed under the Assisted Living & Shared Housing Act, Nursing Home Care Act, ID/DD Community Care Act, or Specialized Mental Health Rehabilitation Act?

    1. Yes
    2. No
53. If Yes, Write the name and address of the facility
55. If Yes to above, was this property occupied by your spouse, who is 65 years of age or older?

    1. Yes
    2. No
56. Did this property remain unoccupied?

    1. Yes
    2. No
58. On January 1, were you liable for the payment of real estate taxes on this property?*

    1. Yes
    2. No
60. Check the type of documentation you have as proof that you are the owner of record or have a legal or equitable interest in the property.*
    -- Select One --DeedTrust agreementLeaseContract for deedLife care contractOther written instrument
61. Write the date the written instrument was executed.
63. If known, write the date recorded and the document number.
65. Notes:
67. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
69. Electronic Signature*
    I state that to the best of my knowledge, the information on this application is true, correct, and complete.
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

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