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RP-459-c (9/09) NEW YORK STATE DEPARTMENT OF TAXATION & FINANCE OFFICE OF REAL PROPERTY TAX SERVICES APPLICATION FOR PARTIAL TAX EXEMPTION FOR REAL PROPERTY OF PERSONS WITH DISABILITIES AND LIMITED INCOMES 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. General information and instructions for completing this form are contained in RP-459-c-Ins 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. Description of nature of applicant’s physical or mental impairment which currently substantially limits one or more major life activities (e.g. walking) 5. Indicate documents submitted with application as proof of disability (See instruction Award letter from Social Security Administration of entitlement to social security disability insurance (SSDI) or supplemental security income (SSI) Award letter from Railroad Retirement Board of entitlement to railroad retirement disability benefits Certificate from State Commission for the Blind and Visually Handicapped stating that applicant is legally blind Award letter from United States Postal Service certifying disability pension Award letter from United States Department of Veterans Affairs certifying disability pension 6. Indicate document submitted with application as proof of ownership (See instruction Deed Mortgage Other (specify) 7. Do all the owners of the property presently occupy the premises as their legal residence? Yes No If answer to question 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. 8. Is any portion of the property used for other than residential purposes (farming, commercial, vacant land, professional office, etc.)? Yes No If answer is Yes, explain such use and describe the portion that is so used. 9. Income of each owner and spouse of each owner for the calendar year immediately preceding date of application MUST be set forth on next page (attach additional sheets if necessary). See instruction #9 for income to be included. (NOTE: Income does NOT include gifts, inheritances or a return of capital.) ---PAGE BREAK--- RP-459-c (9/09) 2 Name of owner(s) Source of income Amount of income Name of spouse(s) if Source of income Amount of income not owner of property of spouse(s) 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.) $ minus #10) $ 11. If a deduction for unreimbursed medical and prescription drug expenses is authorized by any of the municipalities in which property is located (see instructions #11), complete the following: Medical and prescription drug costs; $ Subtract amount of paid or reimbursed by insurance: $ Unreimbursed amount of (attach proof of expenses and reimbursement, if any; enter zero if option not available): $ Total income of owner and spouse [#10 minus #11 $ 12. Did the owner or spouse file a federal or New York State Income Tax return for the preceding year? Yes No If answer is Yes, attach copy of such return or returns. (See instruction #12.) 13. 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 part for the purpose of attending a particular school within the school district? Yes No I certify that all statements made on this application are true and correct. Signature Marital Status Phone No. Date (If more than one owner, all must sign.) Date application filed Exemption applies to taxes levied by or for: Application approved Application disapproved County Town School Village Proof of disability submitted Proof of ownership submitted Assessor’s signature Date SPACE BELOW FOR USE OF ASSESSOR Clear Form