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CITY OF LEWISTON APPLICATION FOR ABATEMENT INABILITY TO PAY - INFIRMITY OR POVERTY INSTRUCTIONS: ALL QUESTIONS MUST BE ANSWERED. YOU MAY BE REQUESTED TO SUPPLY ADDITIONAL DATA TO SUPPORT YOUR REQUEST. A SEPARATE APPLICATION MUST BE SUBMITTED EACH YEAR FOR WHICH THE ABATEMENT IS REQUESTED. CONFIDENTIAL 1. NAME 2. MAILING ADDRESS 3. LEGAL RESIDENCE 4. LENGTH OF TIME AT THIS RESIDENCE HOME PURCHASE 5. TELEPHONE NUMBER HOME CELL 6. DATE OF BIRTH SOCIAL SECURITY NUMBER 7. MARRIED/REGISTERED DOMESTIC PARTNER, SINGLE, WIDOW OR WIDOWER 8. FULL NAME OF SPOUSE/REGISTERED DOMESTIC PARTNER 9. DATE OF BIRTH SOCIAL SECURITY NUMBER 10. TELEPHONE NUMBER HOME CELL 11. ALL HOUSEHOLD MEMBERS (EXCLUDING THE ABOVE): NAME AGE RELATIONSHIP 12. ALL PERSONS LISTED ON THE MORTGAGE: NAME AGE RELATIONSHIP 13. CHILDREN FROM ALL MARRIAGES OR IF NONE, OTHER NEXT OF KIN: NAME AGE ADDRESS RELATIONSHIP ---PAGE BREAK--- PAGE 2 A. INFORMATION REGARDING PROPERTY 14. REAL ESTATE OWNED BY APPLICANT, AND BY SPOUSE OR DOMESTIC PARTNER: TYPE OF PROPERTY (HOME, FARM, WOODLOT, ETC.) LOCATION OWNER'S VALUE 15. YEAR FOR WHICH AN ABATEMENT IS REQUESTED 16. AMOUNT OF ABATEMENT REQUESTED 17. IS THE PROPERTY FOR WHICH YOU ARE REQUESTING AN ABATEMENT USED FOR THE FOLLOWING: RESIDENCE BUSINESS PROPERTY RETAIL PROPERTY 18. DO YOU RECEIVE THE HOMESTEAD EXEMPTION? YES NO TO QUALIFY YOU MUST HAVE OWNED YOUR HOME FOR AT LEAST 12 MONTHS PRIOR TO APRIL 1 OF THE CURRENT YEAR. FORMS MUST BE FILED BY APRIL 1. ALL FORMS FILED AFTER APRIL 1 WILL APPLY TO THE SUBSEQUENT YEAR TAX ASSESSMENT. IF YOU HAVE NOT APPLIED YOU MUST FILE IMMEDIATELY. CONTACT THE ASSESSING OFFICE AT (207) 513-3122. 19. IF APPLICABLE, HAVE YOU APPLIED FOR AND ARE YOU RECEIVING: APPLIED RECEIVING THE LEGALLY BLIND EXEMPTION N/A YES NO YES NO THE VETERAN’S EXEMPTION N/A YES NO YES NO THE WIDOWS AND CHILDREN VETERAN’S EXEMPTION N/A YES NO YES NO B. EMPLOYMENT INFORMATION APPLICANT HOUSEHOLD MEMBER 20. OCCUPATION 21. NAME OF LAST EMPLOYER 22. ADDRESS OF EMPLOYER 23. DATES OF EMPLOYMENT 24. IF ANYONE IS SELF EMPLOYED - PLEASE DESCRIBE THE BUSINESS: 25. IF ANYONE IS UNEMPLOYED, PLEASE STATE THE REASON: 26.IF UNEMPLOYMENT IS DUE TO ILLNESS, ATTACH A PHYSICIANS STATEMENT DESCRIBING THE TYPE AND EXPECTED LENGTH OF DISABILITY. THE PHYSICIAN'S STATEMENT MUST BE CURRENT. ---PAGE BREAK--- PAGE 3 C. INCOME/ASSET INFORMATION 27. DOES THE APPLICANT OR ANY OTHER PERSON IN THE HOUSEHOLD RECEIVE THE FOLLOWING: YES NO AMOUNT YEARLY AMOUNT T.A.N.F. SUPPLEMENTAL SECURITY INCOME SOCIAL SECURITY VETERANS BENEFITS EMPLOYMENT WAGES UNEMPLOYMENT COMPENSATION WORKERS COMPENSATION CHILD SUPPORT PAYMENTS INCOME FROM RENTAL UNITS INCOME FROM BOARDERS OR MEMBERS OF HOUSEHOLD BUSINESS INCOME TAX REFUNDS OTHER INCOME (PLEASE SPECIFY) TOTAL INCOME SNAP HOME ENERGY ASSISTANCE (LIHEAP) TOTAL FROM ALL SOURCES 28. DID YOU RECEIVE A HOMEOWNERS/RENTERS PROPERTY TAX REFUND DURING THE PAST YEAR (PART OF INCOME TAX REFUND)? YES NO IF YES, AMOUNT OF REFUND 29. ATTACH COPIES OF YOUR CURRENT STATE AND FEDERAL INCOME TAX RETURN AND RETURNS FOR THE TWO YEARS IMMEDIATELY PRIOR TO THIS APPLICATION. 30. LIST ALL REAL ESTATE OWNED (INCLUDING PROPERTIES LOCATED OUTSIDE THE CITY OF LEWISTON AND/OR OUTSIDE THE STATE OF MAINE). DESCRIPTION OF CURRENT LOCATION NUMBER OF ASSESSED LAND/BUILDINGS TOWN AND STATE ACRES/VALUE CURRENT USE ---PAGE BREAK--- Page 4 INCOME/ASSET INFORMATION 31. LIST ALL CHECKING ACCOUNTS, SAVINGS ACCOUNTS OR SAFE DEPOSIT BOXES YOU HAVE MAIN- TAINED ALONE OR WITH ANY OTHER PERSON WITHIN THE TWO YEARS IMMEDIATELY PRECEDING THIS APPLICATION, INCLUDING ALL BUSINESS ACCOUNTS. LIST ALL OTHER ASSETS INCLUDING, BUT NOT LIMITED TO, RETIREMENT FUNDS, ANNUITIES, TRUST FUNDS AND STOCKS AND BONDS. A - PERSONAL ACCOUNTS NAME OF BANK/ACCOUNT ACCOUNT # BALANCE CHECKING ACCOUNT SAVINGS ACCOUNT SAFE DEPOSIT BOX B - BUSINESS ACCOUNTS CHECKING ACCOUNT OTHER ACCOUNTS C - RETIREMENT FUNDS D– STOCKS/BONDS E– OTHER ASSETS 32. LIST ALL LIFE INSURANCE POLICIES THAT ARE IN EFFECT NOW AND THAT HAVE BEEN IN EFFECT OVER THE PAST TWO YEARS IMMEDIATELY PRECEDING THIS APPLICATION. POLICY OWNER BENEFICIARY COMPANY AND ADDRESS FACE VALUE CASH VALUE POLICY OWNER BENEFICIARY COMPANY AND ADDRESS FACE VALUE CASH VALUE 33. LIST ALL OTHER ASSETS SUCH AS MOTOR VEHICLES, SNOWMOBILES, BOATS, ALL- TERRAIN VEHICLES, RIDING LAWNMOWERS, ETC., INCLUDING ALL BUSINESS ASSETS DESCRIPTION OF ASSET DATE ACQUIRED CURRENT VALUE LOAN PAYMENT ---PAGE BREAK--- PAGE 5 D. LIABILITY INFORMATION 34. NAME AND ADDRESS OF MORTGAGE HOLDER ARE YOUR TAXES ESCROWED? YES No MORTGAGED AMOUNT (AMOUNT OWED) AVERAGE EXPENSES: MORTGAGE (PRINCIPAL & INTEREST) HOUSE INSURANCE PROPERTY TAXES HEATING FUEL COOKING FUEL ELECTRICITY SEWER WATER TELEPHONE FOOD HOUSEHOLD SUPPLIES PRESCRIPTIONS OTHER MEDICAL SUPPLIES HEALTH INSURANCE LIFE INSURANCE CAR INSURANCE CAR REGISTRATION CAR GASOLINE/TRANSPORTATION LOAN PAYMENTS OTHER (PLEASE SPECIFY) 35. LIST ALL DEBTS: TO WHOM DEBT IS OWED INCLUDING CREDIT CARDS/LOANS NAME AND ADDRESS DATE OF DEBT AMOUNT DUE PAYMENT 36. HAVE YOU INITIATED BANKRUPTCY PROCEEDINGS IN THE PAST 24 MONTHS? YES NO ---PAGE BREAK--- PAGE 6 37. HAS ANY OF YOUR PROPERTY BEEN ATTACHED OR SEIZED UNDER LEGAL PROCEEDINGS WITHIN THE PAST 24 MONTHS? YES NO IF SO, IDENTIFY THE LEGAL PROCEEDINGS, THE PROP- ERTY INVOLVED AND THE PRESENT STATUS OF THE CASE. 38. IS ANY OF YOUR PROPERTY UP FOR SALE? WHAT IS THE LOCATION OF SUCH PROPERTY? WITH WHOM IS THE PROPERTY LISTED? 39. ARE THERE ANY LIENS UPON YOUR PROPERTY AT THIS TIME? PLEASE DETAIL: 40. DURING THE TWO YEARS PRECEDING THIS APPLICATION HAVE YOU OR YOUR SPOUSE/DOMESTIC PARTNER DONE ANY OF THE FOLLOWING: A. PLACED ANYTHING OF VALUE IN WHICH YOU HAVE AN INTEREST IN THE HANDS OF A THIRD PERSON? IF SO, DESCRIBE THE VALUE AND CIRCUMSTANCES OF THE TRANSFER: B. MADE ANY ASSIGNMENT OF ANY PROPERTY FOR THE BENEFIT OF YOUR CREDITORS?________ IF SO, GIVE THE DATES, NAMES AND ADDRESS OF. ASSIGNEE AND TERMS OF ASSIGNMENTS: C. MADE ANY GIFTS, OTHER THEN USUAL PRESENTS TO FAMILY MEMBERS? IF SO, GIVE NAME AND ADDRESSES OF RECIPIENTS AND VALUE OF GIFTS: 41. UPON YOUR AND/OR YOUR SPOUSE'S AND/OR REGISTERED DOMESTIC PARTNER’S DEATH, WHO WILL INHERIT YOUR PROPERTY? NAME ADDRESS RELATIONSHIP ---PAGE BREAK--- PAGE 7 42. IN YOUR OWN WORDS STATE BELOW YOUR REASONS FOR REQUESTING THIS ABATEMENT AND WHY YOU PERSONALLY FEEL YOU QUALIFY FOR A PROPERTY TAX ABATEMENT. MY SIGNATURE ON THIS APPLICATION SHALL SERVE AS AN AUTHORIZATION TO THE CITY COUNCIL, OR THEIR DESIGNEE TO INVESTIGATE THE INFORMATION CONTAINED IN THIS APPLICATION, AND ANY AND ALL OTHER INFORMATION PERTINENT TO THEIR MAKING A DETERMINATION ON THIS APPLICATION. I FURTHER AUTHORIZE THE CITY COUNCIL AND THEIR DESIGNEE TO HAVE ACCESS TO CERTAIN REC- ORDS, BE THEY CONFIDENTIAL OR NOT, INCLUDING BUT NOT LIMITED TO: A. FINANCIAL INSTITUTIONS B. INTERNAL REVENUE SERVICE RECORDS C. MAINE DEPARTMENT OF TAXATION RECORDS D. MEDICAL RECORDS AND REPORTS E. HOSPITAL RECORDS AND REPORTS F. VETERANS ADMINISTRATION RECORDS AND REPORTS G. DEPARTMENT OF HUMAN SERVICES RECORDS AND REPORTS H. SOCIAL SECURITY RECORDS AND REPORTS I. INSURANCE RECORDS J. BUSINESS RECORDS I HEREBY APPLY FOR ABATEMENT OF PROPERTY TAXES IN ACCORDANCE WITH TITLE 36, M.R.S.A., SECTION 841, AS AMENDED, WHICH PERMITS TAX ABATEMENT BY THE MUNICIPAL OFFICERS, OR THE STATE TAX ASSESSOR FOR THE UNORGANIZED TERRITORY WHO MAY ON THEIR OWN KNOWLEDGE OR ON WRITTEN APPLICATION, THEREFORE, MAKE SUCH ABATEMENTS AS THEY BELIEVE REASONABLE IN THE REAL AND PERSONAL TAXES OF ALL PERSONS WHO, BY REASON OF INFIRMITY OR POVERTY, ARE IN THEIR JUDGEMENT, UNABLE TO CONTRIBUTE TO THE PUBLIC CHARGES. THE ANSWERS TO THE ABOVE QUESTIONS ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. APPLICANT SIGNATURE DATE SPOUSE/REGISTERED DOMESTIC PARTNER SIGNATURE DATE Case #