Include ALL 2019 income of ALL persons living in the home. Attach copies of all 2019 year-end income
statements. Attach copies of federal tax returns including all schedules and attachments.
☐ CHECK HERE if you did not file a 2019 Federal Tax Return.
(If non-filer, please supply copies of all 1099’s: social security, pensions, interest, dividends, IRA, 401(k) withdrawals for
EACH household member. OR submit an IRS wage and income transcript AND a verification of non-filing letter.)
1. Wages, Salaries, other Employee Compensation $_________________________________
2. Business, Farm, Rent, Partnership, Sale of Property or Miscellaneous Income $_________________________________
3. Social Security, Railroad Retirement, or Military Retirement: $_________________________________
4. Pensions, Annuities, IRA, 401(k), other Retirement $_________________________________
5. Dividends, Interest, or Trust Income Received $_________________________________
6. Capital Gains not listed above $_________________________________
7. TANF, Worker’s Compensation, Alimony, Child Support, and Strike Benefits $_________________________________
8. Other Income not listed above from all household members $_________________________________
TOTAL 2019 HOUSEHOLD INCOME (Add lines 1 through 8): $_________________________________
Note: NEW applicants and those with a percentage change of disability must provide a letter dated within the last
8 months showing the %
of disability and an effective date of January 1, 2020 or earlier.
☐ I have a combined percentage of disability certified by the Veterans Administration as ____________%
OR ☐ I am the unmarried surviving spouse of a qualifying veteran and will provide a surviving spouse letter from
the VA that shows the veteran’s disability rating.
OR ☐ I am the unmarried surviving spouse of a veteran who was killed in action or died in the line of duty.
(New applicants please submit a copy of DD Form 1300, Report of Casualty, or other evidence of service-connected death.)
☐ I OWNED and OCCUPIED my residence on September 1, 2020 and this property is my primary
Note: Must provide military orders, DD214, or letter from commanding officer confirming dates of service.
☐ I completed at least 200 days of active duty service outside the state of Utah in 2020.
☐ I completed at least 200 consecutive days of active duty service outside the state of Utah across 2019-2020, provided
those days were not counted as qualifying days for tax relief in a prior year.
Note: New applicants must provide a letter from a licensed ophthalmologist verifying visual acuity as listed below.
Letter must be updated every ten years.
☐ I am visually impaired with no more than 20/200 visual acuity in my better eye when corrected; or in the case of better
than 20/200 central vision, have a restriction of the field of vision in the better eye which subtends an angle of vision no
greater than 20 degrees.
OR ☐ I am the unmarried surviving spouse or minor orphan of a deceased blind person.
☐ I OWNED and OCCUPIED my residence on January 1, 2019 and this property is my primary residence.
☐ I hereby certify that I have not applied for property tax relief in any other county in Utah.
I/we declare that the information provided herein is complete, true, and correct. I/we understand that the information
provided is subject to verification by Tooele County, and I/we authorize Tooele County to receive and/or inspect
confidential tax, banking, and investment information from any government office or financial institution.
SECTION 4: HOUSEHOLD INCOME
SECTION 5: DISABLED VETERAN EXEMPTION REQUIREMENTS
SECTION 7: BLIND EXEMPTION REQUIREMENTS
SECTION 8: CERTIFICATION & SIGNATURE
SECTION 6: ACTIVE DUTY MILITARY EXEMPTION REQUIREMENTS