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TOWN OF NILES APPLICATION FOR PARTIAL EXEMPTION FROM GARBAGE DISTRICT ASSESSMENT 1. Name(s) of owner(s) 2. Post office address of owner(s) 3. Location of property: Road address 4. Tax map number 5. Date property was acquired 6. Twenty-five (25%) percent exemption: All occupants of the residence are 65 years or older and use it solely for residential purposes? Yes No If "Yes", list all occupants and their date of birth 7. Fifty (50%) percent exemption: The property you own is occupied for six consecutive months or less per calendar year? Yes No If "Yes", describe the use and period of use of this property__ 8. One hundred (100%) percent exemption: The property’s structure is used exclusively for storage of personal property or agricultural purposes? Yes No If “Yes”, describe the use of this property By applying for this exemption, I (we) CERTIFY that during the calendar year for which this exemption from garbage district assessment is requested, the property is and will qualify. If, at any time during the calendar year for which this exemption is claimed and received, the status of the property should change, I (we) will immediately notify the Town Clerk of the change and make payment of the annual fee in full within five days. I (we) CERTIFY that all statements made on this application are true and correct to the best of my (our) knowledge and belief herein will subject me (us) to the penalties prescribed therefore in the Penal Law of the State of New York. Signature of owner Date Signature of owner Date Mail back to the Town Assessor on or before March 1. SIGN SIGN