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CITY OF LEWISTON MUNICIPAL OFFICERS APPLICATION FOR ABATEMENT INABILITY TO PAY - INFIRMITY OR POVERTY INSTRUCTIONS: All questions should be answered. You may be requested to supply addi- tional date to support your request. An application must be submitted each year for which abatement is requested. 1. NAME 2. MAILING ADDRESS 3. LEGAL RESIDENCE 4. DATE OF BIRTH TELEPHONE NUMBER 5. PLACE OF BIRTH 6. MARRIED OR SINGLE, WIDOW OR WIDOWER 7. SOCIAL SECURITY NUMBER 8. FULL NAME OF SPOUSE 9. DATE OF BIRTH 10. SOCIAL SECURITY NUMBER 11. NAME OF CHILDREN FROM ALL MARRIAGES OR IF NONE, OTHER NEXT OF KIN: NAME AGE ADDRESS RELATIONSHIP A. INFORMATION REGARDING PROPERTY 12. REAL ESTATE OWNED BY APPLICANT, AND IF MARRIED, BY HUSBAND OR WIFE: TYPE OF PROPERTY (HOME, FARM, WOODLOT, ETC.) LOCATION OWNER'S VALUE ---PAGE BREAK--- PAGE 2 13. YEAR FOR WHICH AN ABATEMENT IS REQUESTED 14. AMOUNT OF ABATEMENT REQUESTED 15. IS THE PROPERTY FOR WHICH YOU ARE REQUESTING AN ABATEMENT USED FOR THE FOLLOWING: RESIDENCE BUSINESS PROPERTY RETAIL PROPERTY B. EMPLOYMENT INFORMATION APPLICANT SPOUSE 16. TRADE OR OCCUPATION 17. NAME OF LAST EMPLOYER 18. ADDRESS OF EMPLOYER 19. DATES OF EMPLOYMENT 20. IF SELF EMPLOYED - PLEASE DESCRIBE BUSINESS THAT YOUR OPERATE: 21. IF UNEMPLOYED, REASON: 22.IF UNEMPLOYMENT IS DUE TO ILLNESS, ATTACH A PHYSICIANS STATEMENT DESCRIBING TYPE AND EXPECTED LENGTH OF DISABILITY. THE PHYSICIAN'S STATEMENT SHOULD BE CURRENT. C. INCOME INFORMATION 23. DOES THE APPLICANT OF ANY OTHER PERSON IN THE HOUSEHOLD RECEIVE THE FOLLOWING: YES NO AMOUNT A.F.D.C. SUPPLEMENTAL SECURITY INCOME SOCIAL SECURITY VETERANS BENEFITS FOODSTAMPS EMPLOYMENT WAGES UNEMPLOYMENT COMPENSATION WORKERS COMPENSATION SUPPORT PAYMENTS BY PARENTS HOME ENERGY ASSISTANCE ---PAGE BREAK--- PAGE 3 23. CONTINUED YES NO AMOUNT MEDICAID INCOME FROM RENTAL UNITS INCOME FROM BOARDERS OR MEMBERS OF HOUSEHOLD BUSINESS INCOME OTHER INCOME (PLEASE SPECIFY) TOTAL FROM ALL SOURCES 24. WHAT IS YOUR ANNUAL INCOME: PLEASE ATTACH COPIES OF YOUR STATE AND FEDERAL INCOME TAX RETURN FOR THE TWO YEARS IM- MEDIATELY PRIOR TO THIS APPLICATION. 25. 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 26. LIST ALL CHECKING ACCOUNTS, SAVINGS ACCOUNTS OR SAFE DEPOSIT BOXES YOU HAVE MAINTAINED ALONE OR WITH ANY OTHER PERSON WITHIN THE TWO YEARS IMMEDIATELY PRECEDING THIS APPLICATION, INCLUDING ALL BUSINESS ACCOUNTS. A - PERSONAL ACCOUNTS NAME OF BANK ACCOUNT # BALANCE CHECKING ACCOUNT SAVINGS ACCOUNT SAFE DEPOSIT BOX B - BUSINESS ACCOUNTS CHECKING ACCOUNT OTHERS ACCOUNTS 27. LIST ALL LIFE INSURANCE POLICIES THAT ARE IN EFFECT NOW AND THAT HAVE BEEN IN EF- FECT OVER THE PAST TWO YEARS IMMEDIATELY PRECEDING THIS APPLICATION. COMPANY AND ADDRESS FACE VALUE CASH VALUE ---PAGE BREAK--- PAGE 4 28.LIST ALL OTHER ASSETS SUCH AS MOTOR VEHICLES, SNOWMOBILES, EGATS, ALL- TERRAIN VEHICLES, RIDING LAWNMOWERS, SNOWBLOWERS, ETC., INCLUDING ALL BUSINESS ASSESTS. DESCRIPTION OF ASSET DATE ACQUIRED CURRENT VALUE 29. DID YOU RECEIVE AN ELDERLY HOMEOWNERS/RENTERS PROPERTY TAX REFUND DURING THE PAST YEAR? IF YES, AMOUNT OF REFUND: 30. ARE YOU ENTITLED TO A REFUND THIS YEAR? AMOUNT OF ANTICIPATED REFUND: D. LIABILITY INFORMATION AVERAGE EXPENSES: MORTGAGED AMOUNT MORTGAGE (PRINCIPAL & INTEREST) INSURANCE (HOUSE) TAXES (PROPERTY) FUEL ELECTRICITY COOKING FUEL SEWER WATER TELEPHONE FOOD CLOTHING PERSONAL SUPPLIES HOUSEHOLD SUPPLIES PRESCRIPTIONS OTHER MEDICAL SUPPLIES LIFE INSURANCE TRANSPORTATION LOAN PAYMENTS OTHER (PLEASE SPECIFY) ---PAGE BREAK--- PAGE 5 32. LIST ALL DEBTS: TO WHOM DEBT IS OWED AMOUNT NAME AND ADDRESS DATE OF DEBT DUE PAYMENT 33. HAVE YOU INITIATED BANKRUPTCY PROCEEDING IN THE PAST 24 MONTHS? 34. HAS ANY OF YOUR PROPERTY BEEN ATTACHED OR SEIZED UNDER LEGAL PROCEEDINGS WITHIN THE PAST 24 MONTHS? IF SO, IDENTIFY THE LEGAL PROCEEDINGS, THE PROPERTY INVOLVED AND THE PRESENT STATUS OF THE CASE. 35. IS ANY OF YOUR PROPERTY UP FOR SALE? WHAT IS THE LOCATION OF SUCH PROPERTY? WITH WHOM IS THE PROPERTY LISTED? 36. ARE THERE ANY LIENS UPON YOUR PROPERTY AT THIS TIME? PLEASE DETAIL: 37. DURING THE TWO YEARS PRECEEDING THIS APPLICATION HAVE YOU OR YOUR SPOUSE 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: ---PAGE BREAK--- PAGE 6 38. UPON YOUR AND/OR YOUR SPOUSE'S DEATH, WHO WILL INHEIT YOUR PROPERTY? NAME ADDRESS RELATION 39.IN YOUR OWN WORDS STATE BELOW YOUR REASONS FOR REQUESTING THIS ABATEMENT AND WHY YOU PERSONALLY FEEL YOU QUALIFY FOR A PROPERTY TAX ABATEMENT. 40. HAVE YOU APPLIED FOR THE MAINF RESIDENTS PROPERTY TAX IF YES, WHAT WAS THE AMOUNT OF THE REFUND? ---PAGE BREAK--- PAGE 7 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 HIS 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 HERE BY APPLY FOR ABATEMENT OF PROPERTY TAXES IN ACCORDANCE WITH TITLE 36, M.R.S.A., SECTION 841, AS AMENDED, WHICH PERMITS TAX ABATEMENT EY 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 RE- AL 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. Applicants Signature Date Spouses Signature Date DO NOT WRITE BELOW THIS LINE PROPERTY TAX FOR YEAR APPROVED BY TITLE: