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LONG FORM: PROPERTY TAX EXEMPTION FOR SENIORS Elbert County Assessor 221 Comanche St. PO Box 26, Kiowa, CO 80117 [PHONE REDACTED] Email: [EMAIL REDACTED] CONFIDENTIAL 1. Identification of Applicant and Property Applicant's First Name, Middle Initial and Last Name Social Security No. Date of Birth Property Address (number & street name) Schedule or Parcel Number City or Town State Zip Code Telephone Number CO Mailing Address (if different than property address) Check Box if Ownership is Held in a Life Estate. 2. Age and Occupancy Requirements (One of the following statements must be true.) 2A. As of January 1 of this year, I am 65 years old, I occupy the property listed above as my primary residence, and I have occupied it as my primary residence for at least 10 consecutive years prior to January 1 of this year. True 2B. I am the surviving spouse of an individual who previously qualified for the exemption. Each of the following statements is true: a) My spouse passed away after December 31, 2001; and b) My spouse was at least 65 years old on January 1 of the year he or she passed away; and c) My spouse occupied the property as his or her primary residence for at least 10 consecutive years prior to January 1 of the year in which he or she passed away; and d) I occupied the property with my spouse as our primary residence; and e) I currently occupy the property as my primary residence; and Date of birth of spouse who previously qualified f) I have not remarried. If each of statements a) through f) is true, check here: True 2C. If not for the fact that either I or my spouse was confined to a health care facility, or our prior residence was condemned in an eminent domain proceeding, or our prior residence was destroyed or otherwise rendered uninhabitable by a natural disaster, one of the statements above would be true. If any of these circumstances apply, you must check box 2A or 2B here, Statement 2A would be true and complete section 5, 6 or 7 (as applicable) on the back of this form. Statement 2B would be true 3. Ownership Requirement (One of the following statements must be true.) 3A. The owner of record for the property described above is either a) me, b) my spouse, or c) both of us. The property has been owned by one or both of us for at least 10 consecutive years prior to January 1 of this year. During periods when the property was owned by my spouse and not by me, my spouse and I were married and my spouse occupied the property as his or her primary residence. True 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, or my/our prior residence was condemned in an eminent domain proceeding or was destroyed or otherwise rendered uninhabitable by a natural disaster. (If 3B is true, complete section 6, 7, 8 or 9 on the back of this form.) True 4. List each additional person who occupies the property as his or her primary residence. 4A. Person who also occupies property as primary residence Spouse Social Security Number Yes No 4B.1 Person who also occupies property as primary residence Social Security Number 4B.2 Person who also occupies property as primary residence Social Security Number ---PAGE BREAK--- 5. Complete this section if applicant or spouse was/is confined to a nursing home, hospital, or assisted living facility. 5A. Name of Confined Individual 5B. Location 5C. Dates Confined 5D. During 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 6. Complete this section if prior residence was condemned in an eminent domain proceeding. 6A. Street address of condemned property 6B. Dates of ownership of condemned property from: to: 6C. Dates property was occupied as primary residence 6D. Approximate date of condemnation from: to: 6E. Since the condemnation of my prior residence, I have not owned and occupied any property as my primary residence other than the property for which I am applying for exemption. True 6F. If condemnation of the prior residence had not occurred, the condemned property would still be my primary residence. True 7. Complete this section if prior residence was destroyed or otherwise rendered uninhabitable by a natural disaster. 7A. Street address of destroyed property 7B. Dates of ownership of destroyed property From: To: 7C. Dates property was occupied as primary residence 7D. Date property was destroyed by natural disaster From: To: 7E. If the destruction of the prior residence had not occurred, the destroyed property would still be my primary residence. True 8. Complete this section if property is owned by a trust or an individual as trustee. 8A. Name of Trust 8B. Maker(s) of Trust 8C. Trustee(s) 8D.1 Beneficiary 8D.2 Beneficiary 8D.3 Beneficiary (attach additional sheets if necessary) 8E. The property was transferred to the above-named 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 9. Complete this section if property is owned by a corporate partnership or other legal entity. 9A. Name of Corporate Partnership or Legal Entity 9B.1 Name of Principal 9B.2 Name of Principal 9B.3 Name of Principal (attach additional sheets if necessary) 9C. The property was transferred to the above-named partnership or 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 10. Affidavit and Signature I declare, under penalty of perjury in the second degree 18-8-503, that the information provided on this form and on any attachments is correct. Signature: Date: Signer is: Applicant Spouse Guardian* Conservator* Attorney-in-fact* * Authorization in the form of a court order or power of attorney is required and must be attached to this application. Other Contact (relative, representative, etc.): Telephone Number: You must inform the County Assessor of a change in property ownership or occupancy within 60 days of such change. Mail, FAX, or deliver this form to the County Assessor in the county in which the property is located by July 15. We recommend you obtain a receipt when delivering in person, or mailing by certified mail. You may also call the Assessor to verify the application was received.