4. ASSETS - BALANCES OF ACCOUNTS OR VALUES OF ASSETS ON DECEMBER 31, 2019
Please Attach Copies of
Proof of Income and
Proof of Bank Accounts.
Cash Value of Life Insurance
Address of other Real Estate:
OTHER ASSETS: Auto, Boat, Camper and similar
In order for your application to be processed, you must complete all sections of this application and sign on the
applicant signature line. The Exemption is granted on an annual basis and a new application must be filed each year.
Please be advised that submission of an incomplete application may result in your application being denied. The
information you provide is confidential and not open for public inspection. Applications are subject to audit for up to
I hereby request real estate tax relief and certify that the foregoing statements are true and correct to the best of my
knowledge and belief. I understand that any person falsely requesting tax relief shall be guilty of a Class 3 misdemeanor (NN
§ 40-54). I agree to notify the Office of the Commissioner of the Revenue immediately if any changes occur in respect to my
income, financial worth, or ownership of the property.
I authorize the Commissioner of the Revenue to obtain any verification necessary to both determine and review financial
assistance eligibility. This authorizes release of information to the Commissioner of the Revenue's Office.
YOU MUST PROVIDE PROOF OF INCOME
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