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PROPERTY TAX EXEMPTION APPLICATION FOR QUALIFYING VETERANS WITH A DISABILITY This is a confidential document Elbert County Assessor 221 Comanche St., PO Box 26 Kiowa, CO 80117 [PHONE REDACTED] Email: [EMAIL REDACTED] 1. Identification of Applicant and Property Applicant's Name (First, Middle Initial and Last) Social Security Number Property Address (Number and Street Name) Schedule or Parcel Number (if known) City or Town State CO Zip Code County Mailing Address (if different from property address) Telephone Number Check box if ownership is held in a life estate. Email Address: 2. Disabled Veteran Status (Both of the following statements must be true.) 2A. I received a service-connected disability that has been rated by the United States department of veterans affairs as one hundred percent permanent through disability retirement benefits or, which resulted from a service- connected injury sustained while serving on active duty in the Armed Forces of the United States, OR I am medically retired at 100%, OR I am a veteran who has individual unemployability status. True False 2B. I have attached my VA Summary of Benefits letter verifying my status as a one hundred percent permanent disabled veteran or my individual unemployability status . A VA Summary of Benefits letter can be found at □Yes, my VA Summary of Benefits letter is attached (required) 3. Ownership Requirements (One of the following statements must be true.) 3A. Since January 1 of this year, the above-described property has been continuously owned by me and/or my spouse. If the property has been owned by my spouse and not by me, my spouse and I have been legally married and have lived in the property as our primary residence since January 1. True False 3B. Statement 3A would be true if not for the fact that ownership has been transferred to a trust, corporate partnership, or other legal entity solely for estate planning purposes. True False (If 3B is true, you must complete either section 6 or section 7 on the back of this form.) 4. Occupancy Requirement (One of the following statements must be true.) 4A. As of January 1 of this year, I have occupied the property described above as my primary residence, and neither I, nor my spouse, is receiving the senior citizen or the disabled veterans property tax Exemption on any other property in Colorado. True False 4B. Statement 4A would be true if not for the fact that I am confined to a hospital, nursing home, or assisted living facility. True False (If 4B is true, you must complete section 8 on the back of this form.) 5. List each additional person who occupies the property as his/her primary residence. 5A. Person who also occupies property as primary residence Spouse Yes No Social Security Number 5B.1 Person who also occupies property as primary residence Social Security Number Send Application to: ---PAGE BREAK--- 6. Complete this section if property is owned by a trust or an individual as trustee. 6A. Name of Trust 6B. Maker of Trust 6C. Trustee 6D.1 Beneficiary 6D.2 Beneficiary 6D.3 Beneficiary 6D.4 Beneficiary 6E. The property was transferred to the trust solely for estate planning purposes. Had the property not been Transferred, I and/or my spouse would be the owner(s) of record. True False 7. Complete this section if property is owned by a corporate partnership or other legal entity. 7A. Name of Corporate Partnership or Legal Entity 7B.1 Name of Principal 7B.2 Name of Principal 7B.3 Name of Principal 7B.4 Name of Principal 7C. The property was transferred to the corporate partnership or legal entity solely for estate planning purposes. Had the property not been transferred, I and/or my spouse would be the owner(s) of record. True False 8. Complete this section if disabled veteran is confined to a nursing home, hospital, or assisted Living facility. (Also complete if spouse, not veteran, is owner and is confined to nursing home or similar facility) 8A. Name of Confined Individual 8B. Location of Facility 8C. Dates Confined 8D. Since confinement, the property was occupied by either: a) the spouse of the person confined, b) a financial dependent, or c) the property remained unoccupied True False 9. Affidavit and Signature I declare, under penalty of perjury in the second degree 18-8-503, C.R.S.) that the information provided on this form and on any attachments is correct. Signature: Date: Signer is: Applicant Spouse Guardian* * Authorization in the form of a court order or power of attorney is required. Other Contact: Conservator* Attorney-in-fact* Telephone Number: (Relative or other contact) The County Assessor must be informed of any change in ownership or occupancy of the property or changes to unemployability status within 60 days of such occurrence. Mail, FAX, or deliver this form to the County Assessor no later than July 1. We recommend you obtain a receipt when delivering the form in person or by FAX or mail the form by certified mail. You may contact the County Assessor after September 1 to confirm the exemption has been applied to your property. 5B.2 Person who also occupies property as primary residence Social Security Number 5B.3 Person who also occupies property as primary residence Social Security Number 5B.4 Person who also occupies property as primary residence Social Security Number