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4. Year for which you are applying for:*
   -- Select One --20222023
6. Parcel ID number, PIN, Tax ID*
7. Township
8. Date of Birth*
   Date of Birth
10. First Name*
11. Last Name*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Email Address
24. Have you or your spouse received this exemption for this property previously?*

    1. Yes
    2. No
26. If your spouse maintains a separate residence, has he or she applied for this exemption?*

    1. Yes
    2. No
30. Income Information

    Please use the income information from the prior year.

32. Please Upload Proof of Income:

    Federal Income Tax Return or end of the year Social Security statement from prior year

34. 1. Social Security and SSI benefits. Include Medicare deductions in this total. (Full Social Security)*
35. 2. Railroad Retirement benefits. Include Medicare deductions in this total. *
37. 3. Civil Service benefits*
38. 4. Annuities, federally taxable pensions and retirement plan distributions. *
40. 5. Human Services and other governmental cash public assistance benefits *
41. 6. Wages, salaries, and tips from work*
43. 7. Interest and dividends received*
44. 8. Net rental, farm, and business income or (loss). *
46. 9. Net capital gain or (loss). *
47. 10. Other income or (loss).*
49. 11. Add Lines 1 through 10.*
51. 12. Certain subtractions. You may subtract only the reported adjustments to income from U.S. 1040, Schedule 1, Line 22.
53. 13. Subtract Line 12 from Line 11, and write the result. This is your total household income for the prior year. If the amount is greater than $65,000, STOP. You do not qualify for this exemption*
55. Assessor verified:

    1. Yes
    2. No
56. For Assessor use:

    Initials

58. Part 4: Affidavit

60. 1. On January 1st, the property identified in Part 2, Line 1, was improved with a permanent structure*

    1. A. That I used as my principal residence

    1. B for which I received this exemption previously and is either unoccupied or used as my spouse’s principal residence. I am now a resident of a facility licensed under the Assisted Living Care Act
62. 2. On January 1st, I*

    1. A. was the owner of record of the property identified in Part 2, Line 1.
    2. B. had a legal or equitable interest by a written instrument in the property listed in Part 2, Line 1.
    3. C. had a leasehold interest in the property identified in Part 2, Line 1, that was used as a single-family residence.
64. 3. I am liable for paying real property taxes on the property identified in Part 2, Line 1.*

    1. Yes
    2. No

    Note: If I have not received this exemption for this property previously, I also met the eligibility requirements listed in Part 4, Lines 1, 2, and 3 for this property on January 1st.

    
    

66. 4. (Mark the statement that applies.)

    1. A. In the year stated above, I am, or will be, 65 years of age or older.
    2. B. In the year stated above, my spouse, who died in the current year, would have been 65 years of age or older. (Complete the following information.)
68. Name on Death Record
69. Date of Birth
    Date of Birth
70. Date of Death
    Date of Death
72. 5. The property identified in Part 2, Line 1, is the only property for which I am applying for a senior citizens assessment freeze homestead exemption for the year stated above,*

    1. Yes
    2. No
74. 6. The amount reported in Part 3, Line 13, of this form includes the income of my spouse and all persons living in my household and the total household income for the year prior to the year stated above, is $65,000 or less*

    1. Yes
    2. No
76. 7. In the year stated above, the following individuals also used the property identified in Part 2, Line 1, for their principal residence. My spouse is included if he or she used the property as his or her principal dwelling place on January 1. The total income of all individuals and my spouse (regardless of his or her principal residence) are included in Part 3.
78. 8. In the year stated above, on January 1st, I was *

    1. single, widow(er), or divorced.
    2. married and living together
    3. married, but not living together.
80. My spouse’s name and address (if different)is:
81. First Name
82. Last Name
84. Address
85. City
86. State
87. Zip Code
89. Under penalties of perjury, I state that, to the best of my knowledge, the information contained in this affidavit is true, correct, and complete
91. 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.
93. Electronic Signature*
94. Date:
    Date:
96. Note: The CCAO may conduct an audit to verify that the taxpayer is eligible to receive this exemption.
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit

* indicates a required field