Fillable Application For Disabled Persons With Limited Incomes (Town of East Hampton)

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Application For Disabled Persons With Limited Incomes (Town of East Hampton)

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U.S.A. forms for Town of East Hampton

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RP-459-c (9/09)
NEW YORK STATE DEPARTMENT OF TAXATION & FINANCE
OFFICE OF REAL PROPERTY TAX SERVICES
APPLICATION FOR PARTIAL TAX EXEMPTION FOR REAL PROPERTY OF
PERSONS WITH DISABILITIES AND LIMITED INCOMES
APPLICATION MUST BE FILED WITH YOUR LOCAL ASSESSOR BY TAXABLE STATUS DATE
Do not file this form with the Office of Real Property Tax Services.
General information and instructions for completing this form are contained in RP-459-c-Ins
l. Name and telephone no. of owner(s) 2. Mailing address of owner(s)
Day No. ( )
Evening No. ( )
E-mail address (optional) ___________________________________________________________________
3. Location of property (see instructions):
Street address
City/Town Village (if any)
School District
Property identification (see tax bill or assessment roll)
Tax map number or section/block/lot
4. Description of nature of applicant’s physical or mental impairment which currently substantially limits one or
more major life activities (e.g. walking)
5. Indicate documents submitted with application as proof of disability (See instruction #5)
Award letter from Social Security Administration of entitlement to social security disability insurance
(SSDI) or supplemental security income (SSI)
Award letter from Railroad Retirement Board of entitlement to railroad retirement disability benefits
Certificate from State Commission for the Blind and Visually Handicapped stating that applicant is legally
blind
Award letter from United States Postal Service certifying disability pension
Award letter from United States Department of Veterans Affairs certifying disability pension
6. Indicate document submitted with application as proof of ownership (See instruction #6):
Deed Mortgage Other (specify)
7. Do all the owners of the property presently occupy the premises as their legal residence? Yes No
If answer to question 7 is No, is an owner receiving medical care as an in-patient in a residential health care
facility?
Yes No If answer is Yes, specify name and location of the facility.
8. Is any portion of the property used for other than residential purposes (farming, commercial, vacant land,
professional office, etc.)?
Yes No If answer is Yes, explain such use and describe the portion
that is so used. __________________________________________________________________________
________________________________
_______________________________________________________
9. Income of each owner and spouse of each owner for the calendar year immediately preceding date of
application MUST be set forth on next page (attach additional sheets if necessary). See instruction #9 for
income to be included. (NOTE: Income does NOT include gifts, inheritances or a return of capital.)
RP-459-c (9/09)
2
Name of owner(s) Source of income Amount of income
______________________________ _______________________________ ____________________
______________________________ _______________________________ ____________________
______________________________ _______________________________ ____________________
Name of spouse(s) if Source of income Amount of income
not owner of property of spouse(s) of spouse(s)
______________________________ _______________________________ ____________________
______________________________ _______________________________ ____________________
______________________________ _______________________________ ____________________
Subtotal income of owner(s) and spouse(s) $ ___________________
10. Of the income specified in #9 how much, if any, was used to pay for an
owner’s care in a residential health care facility? (See instruction #10)
(Attach proof of amount paid: enter zero if not applicable.) $ ___________________
(#9 minus #10) $ ___________________
11. If a deduction for unreimbursed medical and prescription drug expenses is
authorized by any of the municipalities in which property is located
(see instructions #11), complete the following:
(a) Medical and prescription drug costs; $ ___________________
(b) Subtract amount of (a) paid or reimbursed by insurance: $ ___________________
(c) Unreimbursed amount of (a) (attach proof of expenses and
reimbursement, if any; enter zero if option not available): $ ___________________
Total income of owner (s) and spouse (s) [#10 minus #11 (c)] $ ___________________
12. Did the owner or spouse file a federal or New York State Income Tax return for the preceding year?
Yes No If answer is Yes, attach copy of such return or returns. (See instruction #12.)
13. Does a child (or children), including those of tenants or lessees, reside on the property and attend a public
school, grades K through 12?
Yes No
If Yes, show name and location of school(s): __________________________________________________
_______________________________________________________________________________________
If Yes, was the child (or were the children) brought into the residence in whole or in substantial part for the
purpose of attending a particular school within the school district? Yes No
I certify that all statements made on this application are true and correct.
Signature Marital Status Phone No. Date
(If more than one owner, all must sign.)
Date application filed Exemption applies to taxes levied by or for:
Application approved Application disapproved County Town
School Village
Proof of disability submitted Proof of ownership submitted
____________________________________________ ______________________________________
Assessor’s signature Date
SPACE BELOW FOR USE OF ASSESSOR
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Application For Disabled Persons With Limited Incomes (Town of East Hampton)

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Completed 15 July 2020

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