Fillable COVID-19 Deferral Form REVISION Fillable.with Signature

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COVID-19 Deferral Form REVISION Fillable.with Signature

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PLEASE PRINT LEGIBLY
MUNICIPALITY / QUASI-MUNICIPALITY NAME: ______________________________________________________________
APPLICATION FOR MUNICIPAL/QUASI-MUNICIPAL TAX RELIEF DEFERRAL PROGRAM
UNDER EXECUTIVE ORDER 7S AND EXECUTIVE ORDER 7W
For deferral of real estate, motor vehicle, and personal property taxes and/or municipal electric, water and sewer,
or C-PACE Benefit Assessment charges due between and including April 1, 2020 and July 1, 2020.
1. PROPERTY OWNER NAME
LAST FIRST
MIDDLE INITIAL
DATE OF BIRTH
2. IF YOU ARE NOT THE OWNER, YOUR AUTHORITY TO MAKE THIS APPLICATION ON THE OWNER’S BEHALF
(E.G., BUSINESS’S MANAGER, INDIVIDUAL POWER-OF-ATTORNEY, ETC.)
3. MAILING ADDRESS
NUMBER AND STREET MUNICIPALITY STATE ZIP CODE
4. DAYTIME TELEPHONE
WITH AREA CODE
EMAIL ADDRESS
5. PROPERTY FOR WHICH DEFERRAL IS REQUESTED
ADDRESS(ES) OF REAL ESTATE: ________________________________________________________________________________________
YEAR, MAKE, MODEL OF VEHICLE(S): __________________________________________________________________________________
TYPE(S) OF PERSONAL PROPERTY: _____________________________________________________________________________________
DEFERRAL PROGRAM: I request that the applicable real estate, motor vehicle, and personal property taxes and any municipal
electric, water or sewer charges or assessments on the property identified above, which would otherwise be due between and
including April 1, 2020 and July 1, 2020, be deferred until three (3) months after the original due date of each without interest or
penalty.
Deferral, for purposes of this program, means that the tax or charge can be paid up to three (3) months after its due date
without interest or penalty.
CHECK PROPER ELIGIBILITY:
Resident: My household has suffered a reduction in income of at least 20% due to COVID-19.
Since April 1, 2020, I either (1) have been furloughed without pay; (2) had my hours significantly reduced; or (3) am
unemployed. This has resulted in at least a 20% reduction in my household income.
Proof of Residency is attached (i.e. a copy of driver’s license, utility bill, or other proof of residency)
Business / Non-Profit: Revenue is expected to decrease at least 30% in the April to June 2020 period versus the April to June
2019 period at this property.
Proof of Ownership is attached (i.e. copy of my business license, utility bill, Secretary of State listing, or other proof of
ownership)
LANDLORDS - Fill Out this Section only if you are the landlord of the real estate listed above.
Deferral Program. If the municipality has adopted the Deferral Program, I request that the applicable real estate taxes
and any municipal electric, water or sewer charges or assessments on the property identified above, which would otherwise be
due between and including April 1, 2020 and July 1, 2020, be deferred until three (3) months after the original due date of each
without interest or penalty.
I have attached documentation proving that the property has or will suffer a significant revenue decline, OR
I have attached documentation proving that commensurate forbearance was offered to the tenants or lessees.
“Commensurate forbearance, for purposes of this program, means either a) a deferral of 25% of rent (approximating
the property tax portion of rent) for the three (3) months after its due date; b) a deferral of one month’s rent to be paid
over the three (3) month period, or c) forbearance substantially similar to (a) or (b) as determined by the tax collector.
Documentation includes, but is not limited to, proof that some tenants or lessees have received forbearance or that the
landlord has actively communicated with tenants or lessees to offer forbearance.
CERTIFICATION:
(A) I am aware of the amount and/or basis of the taxes, charges, and assessments that I am requesting to be deferred and I
hereby irrevocably waive all rights to appeal or dispute them on any basis. I understand that the municipality’s lien,
priority, and enforcement rights will remain unaffected during and after this period.
(B) I understand that this request, if approved, will not defer any taxes, charges, fees, or assessments I may
owe the
municipality which came due before April 1, 2020 or after July 1, 2020 or the interest and penalties applicable to them, or
any other debt I may owe the municipality at any time.
(C) I authorize the municipality and its agents to verify the statements above, and any certification information I have
provided, from its records and other third parties. I consent to those third parties releasing relevant information to the
municipality and its agents for this purpose upon the municipality’s request and that a copy of this application shall be
adequate evidence of my consent. I hold the municipality harmless in their collection of this data.
(D) I understand that I must pay all taxes, charges, and assessments deferred in full (i) within three (3) months after the
original due date or (ii) immediately, if the municipality determines that I am not eligible for deferment. I understand that
if I fail to make payments as noted in this section, all interest, fees, and penalties will be applied to all unpaid portions
retroactive to the original due date.
APPLICANT'S
ATTESTATION
Under penalties of perjury, I hereby swear or affirm that that I have read and understood all of the
statements above, that they are true and accurate, and that I have attached any and all additional
information necessary to process my application herein. I attest that this application, and all attachments,
are genuine and unaltered.
X
Date signed (Mo., Day,Yr.)
_______/________/______
STOP! DO NOT WRITE BELOW THIS LINE
FOR TAX COLLECTOR’S USE ONLY
DEFERRAL FOR: Real Estate Tax Motor Vehicle Tax Supp. Motor Vehicle Tax Personal Property Tax
Water Charges Sewer Usage Charges Sewer Assessment Charges Electric Charge
C-PACE
TAX COLLECTOR’S
DETERMINATION
__ I am satisfied that the applicant meets all the necessary statutory requirements
__ This claim is denied for the following reason(s):
SIGNATURE OF TAX COLLECTOR OR MEMBER OF TAX COLLECTOR’S STAFF
X
Date signed (Mo.,Day,Yr.)
_______/________/______
OPM M-COVID19
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COVID-19 Deferral Form REVISION Fillable.with Signature

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Completed 11 July 2020

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