PLEASE PRINT OR TYPE STATE OF CONNECTICUT ______GRAND LIST
M-59a Rev 12/2019 OFFICE OF POLICY AND MANAGEMENT
BIENNIAL APPLICATION FOR ADDITIONAL VETERAN’S EXEMPTION
FILING PERIOD FEBRUARY 1
st
- OCTOBER 1
st
1. NAME (Last) (First) (Middle Initial)
2. SPOUSE’S NAME (Last) (First) (Middle Initial)
3. PROPERTY LOCATION (No. and Street) CITY OR TOWN STATE ZIP CODE
MAILING ADDRESS (If different from above)
4. MARITAL STATUS: MARRIED or UNMARRIED: SINGLE DIVORCED WIDOW/WIDOWER LEGALLY SEPARATED
5. QUALIFYING INCOME (INCOME FROM ALL SOURCES FOR LAST CALENDAR YEAR):
NOTE: VETERANS’ DISABILITY PAYMENTS ARE NOT CONSIDERED INCOME FOR THIS PROGRAM.
a. GROSS INCOME – Examples: Wages, Bonuses, Commissions, Fees, Gratuities, Payment for Jury Duty
allowance), Lottery winnings, Taxable portion of Annuities and Pensions (including Vetera
n’s), Taxable portion of IRA’s,
Interest, Dividends, Net rent or proceeds from sales of property, etc.
If you are required to file a Federal Income Tax Return, enter the amount of Adjusted Gross Income
Plus any other income and attach a copy of the return to this application. a. $_____________________
b. NON-TAXABLE INTEREST - Example: Interest from Tax Exempt Government Bonds b. $_____________________
c. SOCIAL SECURITY OR RAILROAD RETIREMENT INCOME – (GROSS AMOUNT) Exclude only if 100% disabled
by the United States Department of Veterans Affairs. c. $_____________________
d. ANY INCOME NOT REFLECTED IN THE ABOVE - Examples: Federal Supplemental Security Income,
State of Connecticut public assistance payments, General Assistance, Veteran's Pensions, and any other
income not listed above.
d. $_____________________
e. TOTAL Add lines 5a through 5d e. $_____________________
6. Are you presently receiving a 100% disability rating from the U.S. Dept. of Veterans Affairs? Yes No
AFFIDAVIT
The Applicant herein claims a property tax exemption under provisions of the General Statutes, deposes that
the above statements are true and complete and that he/she is not receiving a State exemption in accordance
with Section 12-81g in any other town or city. The signature below indicates that this affidavit has been read
SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
X
Date signed (Mo, Day, Yr)
_______/________/______
STOP ! DO NOT WRITE BELOW THIS LINE - FOR ASSESSOR'S USE ONLY
8. THE APPLICANT IS RECEIVING THE FOLLOWING VETERAN’S EXEMPTION (“A” Code):
Amount $ ______________________
9. ADDITIONAL EXEMPTION ALLOWED (“B” Code):
(If less than full additional exemption used, NOTE FULL EXEMPTION here $ ________________________)
$ ____________________
10. ADDITIONAL EXEMPTION ALLOWED: PUBLIC ACT 13-224 MUNICIPAL OPTION
(If less than full additional exemption used, NOTE FULL EXEMPTION HERE $ _______________________) $ ___________________
11. EXEMPTION APPLIED TO: Real Estate
Motor Vehicle
Personal Property
Supplemental Motor Vehicles
AFFIDAVIT
______ I am satisfied that the above named applicant meets all the necessary statutory requirements
______ This claim is disallowed for the following reason: ___________
____________________________
SIGNATURE OF ASSESSOR OR MEMBER OF ASSESSOR'S STAFF
Date signed (Mo.,Day,Yr.)
_________/_________/______
