Fillable 2021 Tax Relief Application 1st Time Filer Fillable (Montgomery County, Virginia)

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2021 Tax Relief Application 1st Time Filer Fillable (Montgomery County, Virginia)

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MONTGOMERY COUNTY
HELEN P. ROYAL, MASTER COMMISSIONER OF THE REVENUE
755 ROANOKE ST SUITE 1A CHRISTIANSBURG, VA 24073
APPLICATION FOR TAX RELIEF FOR THE ELDERLY AND DISABLED
Parcel ID:
PPID:
M0#:
Senior
Disabled
Tax District
1. APPLICANT INFORMATION (Please Print Clearly)
Name of Applicant
Last, First, Middle
Social Security Number
Date of Birth
Name of Spouse
Last, First, Middle
Social Security Number
Date of Birth
Property Address
Street, City, Zip code
Phone Number
If you are retired, Where are you retired from?
A.
Do you own and live at the above address?
Yes
No
B.
Does anyone live in the house other than the spouse?
Yes
No
C.
Is any portion of the house rented to another person?
Yes
No
D.
Do you have a live in caregiver?
Yes
No
E.
Do you own any real estate other than this house?
Yes
No
F.
Have you sold or transferred any real estate, stocks, bonds,
bank account or personal property the previous year?
Yes
No
2. OTHER PERSONS LIVING AT THE ABOVE ADDRESS (If no other persons live with you, write "NONE")
Name
Social Security
Relationship to owner
Date of Birth
PERSON 1
PERSON 2
3. TOTAL ANNUAL COMBINED GROSS HOUSEHOLD INCOME-JANUARY 1, 2020 TO DECEMBER 31, 2020
Income From:
Applicant
Spouse
Person 1
Person 2
Wages / Unemployment
$
$
$
$
Social Security
$
$
$
$
Railroad Retirement
$
$
$
$
Veteran's Benefits
$
$
$
$
Pensions
$
$
$
$
Interest
$
$
$
$
Dividends
$
$
$
$
Rental Income
$
$
$
$
Fuel Assistance
$
$
$
$
Food Stamps
$
$
$
$
Other: _____________
$
$
$
$
Total Income:
$
$
$
$
GRAND TOTAL:
$
Office Use – Income
Office Use – Net Worth
Office Use – Levy
Office Use – Abatement
Office Use – MH
2021
First Time Filer
4. ASSETS - BALANCES OF ACCOUNTS OR VALUES OF ASSETS ON DECEMBER 31, 2020
Applicant
Spouse
Please Attach Copies of
Proof of Income and
Proof of Bank Accounts.
Real Estate
$
$
Checking Accounts
$
$
Savings Accounts
$
$
CD's
$
$
Cash Value of Life Insurance
$
$
Stocks
$
$
Address of other Real Estate:
Bonds
$
$
IRA's/401k's/Annuities
$
$
Office Use
Total Assets – Abatement = Net Worth
Other Real Estate
$
$
Other: ______________________
$
$
OTHER ASSETS: Auto, Boat, Camper and similar
Type
Year
Make
Model
Value
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Boat/RV
Boat/RV
Trailer
Trailer
Camper
Camper
5. AFFIDAVIT
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
three years.
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.
Signature
Date
YOU MUST PROVIDE PROOF OF INCOME
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2021 Tax Relief Application 1st Time Filer Fillable (Montgomery County, Virginia)

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Completed 5 July 2021

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