Fillable DISABLED VETERANS REAL ESTATE TAX EXEMPTION PROGRAM APPLICATION (County of York)

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DISABLED VETERANS REAL ESTATE TAX EXEMPTION PROGRAM APPLICATION (County of York)

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DISABLED VETERANS’
REAL ESTATE TAX EXEMPTION PROGRAM
APPLICATION FOR EXEMPTION FROM REAL PROPERTY TAXES
Every blank must have an entry or the application will be returned. No determination can
be made until all required information is provided.
Important Facts to Remember when Applying:
Type or Print clearly all requested information
The affidavit at the end of the application must be processed through your local County Director
for Veterans’ Affairs
New Applications must be Date Stamped by your County Tax Assessor’s Office
Documents Required:
VA Form 3288 - With highlighted areas only filled out and signed - SEE ATTACHED
Copy of Property Deed
Military Discharge (DD 214) showing wartime service
Marriage Certificate (Surviving Spouse application only)
Veteran’s Death Certificate (Surviving Spouse application only)
Income Verification Documentation Required (if Applicable):
1040 Federal Income Tax Return (If you are required to file)
1040 Schedules: C (Business); D (Capital Gains); E (Rental Income); F (Farm Income)
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Employment Income (most recent W-2)
Social Security Benefit Statement (Form SSA-1099)
Interest Income (Form 1099-INT)
Dividend Income (Form 1099-DIV)
Distribution from Pensions, Annuities, Retirement or Profit Sharing Plans, IRA’s, Insurance
Contracts, etc. Form 1099-R; 1099-MISC; 1099-C (Cancellation of Debt); W-2G (Gambling Earnings)
Expense Documentation Required
** If the Claimant’s income is greater than $92,594 **
Privacy Act Statement.
Principal Purpose: This application form is the primary source of information to determine eligibility for the Real
Property Tax Exemption Program for certain disabled veterans and their unmarried surviving spouses.
Routine Use: The information you provide will be used to review and determine your eligibility for exemption for real
property taxes under Article 8, Section 2(c) of the Pennsylvania Constitution, 51 Pa.C.S. Ch. 89 and 43 Pa Code
Ch.5 Sub-Chapter C. The information may be provided to federal, state and local agencies, including your local
taxing authorities, in connection with review of your application.
Voluntary Disclosure: Responding to this collection of information is voluntary. However, if the information is not
furnished, we may not be able to comply with your request.
MA-VA Form 40 January 2019 (All previous editions are obsolete.)
** Authority: 51 Pa.C.S. Chapter 89. **
Instructions for Completing the Application
General Information:
If you are a Veteran, Check the block for “Veteran”.
If you are a Surviving Spouse of a qualified Veteran, check the block “Surviving Spouse”.
If the Veteran was living during the last review period, but is now deceased, the Surviving
Spouse must contact their local County Director of Veterans Affairs and complete a new
application to transfer the benefit.
Section A: All information in this Section is REQUIRED.
Section B: All information in this Section is REQUIRED.
Section C: Eligibility Criteria: Check all blocks that apply.
Section D: Exemptions and Dependent Data: Members of Your Immediate Family Residing in the
Household - List the names of all dependents, their relationship to the Veteran, and their date of
birth. Children may be counted as dependents only until they are 18 years old unless they are in
school on a full-time basis and under the age of 24, or they are unable to care for themselves.
Section E: Property Information: Check appropriate block(s). Does any portion of the property
generate income?
Section F: Income: List gross annual income for the previous tax year. If the applicant is a
Veteran with a Spouse, indicate the individual’s income in the appropriate columns. Yearly
interest and/or dividend income earned from savings accounts, stocks, bonds, annuities, trust
funds or other securities are also required. No adjustments to, or deductions from, income will be
authorized in determining applicability of the rebuttable presumption. Attach the required
income verification documentation listed in the Required Documents column.
Income defined in 43 Pa Code § 5.22 is as follows: salaries, wages, bonuses, commissions, income
from self-employment, support money, cash public assistance and relief; the gross amount of
pensions or annuities, including railroad retirement benefits; benefits received under the Social
Security Act except Medicare benefits; benefits received under state unemployment insurance laws
and Veterans’ disability payments; interest received from the federal or state government or an
instrumentality or political subdivision thereof; realized capital gains; rentals; workmen's
compensation and the gross amount of loss-of-time insurance benefits and proceeds except the first
$5,000 of the total of death benefit payments; and gifts of cash or property other than transfers by
gift between members of a household in excess of a total of $300. This term does not include
surplus food or other relief in kind supplied by a governmental agency. Income from savings
accounts and bonds shall be included as well as interest received from investments.
Section G: Expenditure Documentation - If the applicant’s annual income exceeds $ 92,594,
this section must be completed. All financial entries on the application require documentation
in the form of a copy of a bill, receipt, or invoice for expenses incurred within the tax period
being evaluated. Only one recent bill is necessary for those expenses that recur each month, e.g.
mortgage. Receipts and bills should be organized by category.
Section H: Affidavit: This section must be Dated, Signed by the Claimant and the
County Director of Veterans’ Affairs or Designated County VSO.
VA Form 3288 – Veteran need only complete the highlighted areas. VA Form 3288
must be submitted with the Application for Determination of Financial Need.
New Applications Require a
Date Stamp by Your County
Tax Assessment Office here.
APPLICANT DATA
V.A. Claim #
A
Veteran’s Last Name First Name M/I Social Security # (Required)
Property Address
Mailing Address
City State Zip +4 County
B
Birth Date: (Mo) (Day) (Year)
Phone
Spouse’s Last Name First Name M/I Social Security #
Current Address You Occupy Birth Date: (Mo) (Day) (Year)
City State Zip +4 County Phone
ELIGIBILITY CRITERIA
1. Did the Veteran have Active Duty Service in any War or Armed Conflict in which the United States was engaged?
YES NO
2
. As a result of such service is the Veteran rated total or 100% permanently disabled by the U.S. Department of Veterans’ Affairs? YES NO
3. If deceased, was the Veteran rated total or 100% permanently disabled (service-connected) by the U.S. Department of
Veterans’ Affairs during his lifetime?
YES NO
4. As a resu
lt of such Military Service is the Veteran blind or paraplegic or has he sustained the loss of two or more limbs? YES NO
Is the Veteran
Age 65 or
Older
100% Disabled Blind Paraplegic Double Amputee
Is the Spouse
Age 65 or Older
C
DEPENDENT AND EXEMPTION DATA D
List members of your immediate family residing in the household (except the spouse listed in Section B) who are dependents
MA-VA Form 40 January 2019 (All previous editions are obsolete)
APPLICATION FOR DETERMINATION OF FINANCIAL NEED FOR REAL PROPERTY TAX EXEMPTION
APPLICANT: Are you the Veteran or Spouse (All Information in Section A and B is Required)
Page 1 of 3
NAME RELATIONSHIP BIRTHDATE
Office of the Deputy Adjutant General for Veterans Affairs
Ft. Indiantown Gap, Annville, PA 17003-5002
800-547-2838
New Application
Review Application
Email Address
Under Section 8902 of the Military and Veterans Code, 51 Pa. C.S. § 8902 (3) provides that the dwelling must be owned by that person
solely, with his or her spouse or as an estate by the entireties.
1. Is the property titled in the applicant’s name solely? OR
YES
NO
2. Is the property titled jointly in the Veteran’s and spouse’s names? YES
NO
3. Is the property occupied as the principal dwelling by the person seeking the exemption? YES
NO
4. Does any portion of the property generate income (if yes please explain below) YES
NO
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
5. Do you own any other real estate that you do not occupy? YES
NO
6.
If Yes to question 5
a. Non—Rental Address: ______________________________________________________________
b. Rental Income: provide annual amount of rent in the appropriate block in Section F (1040 Schedule E).
- Address of rental property (s): __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
YES
NO
PROPERTY INFORMATION E
INCOME F
Are you exempt from filing Income Taxes (Form 1040)?
Do you affirm that your gross annual income is less than $ 92,594?
YES NO
Source of Information
Required Documents
If Applicable
Spouse’s Income
Supporting documentation for all income is required
VA Compensation
VA Compensation Rate
Veteran’s Income
Social Security
SSA—Form 1099
Gross Employment Income
Form W2
Civil Service Annuity
Form 1040 Tax Return
Retirement/Pension
Form 1099-R
Blind/Paralyzed Pension
Rent from Property (Schedule E)
Lease Agreement/Form 1040
Gifts, Inheritance & Death Benefits
Form 1099—INT
Form 1099—DIV
Form 1040 Tax Return
Yearly Interest (Schedule B)
Yearly Dividends (Schedule B)
Yearly Capital Gains (Schedule D)
Other Income (1099-MISC, 1099-C,
W2G)
Form 1040 Tax Return
TOTAL INCOME
$
Page 2 of 3
$
G
EXPENDITURE DOCUMENTATION
IF THE APPLICANTS ANNUAL INCOME ALONE IS $ 92,594 OR LESS, DO NOT COMPLETE THIS SECTION
MONTHLY EXPENSES
1. Mortgage Payment _____________________________ 11. Domestic Help ____________________________________
(Indicate below costs included in mortgage payment) 12. Educational Costs _________________________________
Principal Interest Mortgage Ins. Taxes 13. Home Improvement (s) Over $200 _____________________
2. Real Estate Tax ________________________________ 14. Major Purchases Over $200 (includes car bought
3. Loan Payments ________________________________ for cash) __________________________________________
4. Car Payment __________________________________ 15. Medical Bills for Legal Dependents ____________________
(Form 1040 Schedule A)
5. Average Monthly E
lectric Power __________________ 16. Car Repairs (over $100 not covered by
6. Average Monthly Home Heating Fuel ______________ insurance) ________________________________________
7. Water ________________________________________ 17. Lot Rental __________________________________________
8. Sewage _______________________________________ 18. Miscellaneous Bills
9. Trash Removal ________________________________ (Auto, Homeowner’s, Health & Life Insurance Premiums;
10. Telephone ___________________________________ Cable TV, Internet Service and Major Credit
Cards) ___________________________________________
PLEASE ATTACH SUPPORTING DOCUMENTATION IN THE FORM OF RECEIPTS OR BILLS
AFFIDAVIT H
READ THIS NOTICE BEFORE SIGNING
By signing this application, the applicant certifies that the information provided is true and correct to the best of his
knowledge, information and belief. The law provides severe penalties including fines and imprisonment for making
false statements on official forms such as this Application for Exemption from Real Property Taxes. I understand that
this verification is made subject to the penalties of 18 Pa C.S.A. § 4904 pertaining to unsworn falsification to
authorities.
THIS AFFIDAVIT MUST BE SIGNED BY THE APPLICANT:
______________________________________ _________________
Signature of Claimant Date
________________________________________
Printed Name of Claimant
Processed By:_________________________________________________________________________________
Signature of County Veterans’ Affairs Director or Designated County VSO
Mail completed application to:
Page 3 of 3
Office of Veterans Affairs
ATTN: Real Estate Tax Exemption
Bldg S-0-47, Fort Indiantown Gap,
Annville, PA 17003-5002
click to sign
signature
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REQUEST FOR AND CONSENT TO RELEASE OF INFORMATION FROM CLAIMANT’S RECORDS
Privacy Act Statement: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is
solicited under Title 38, United States Code, and will authorize release of the information you specify. The information may also be disclosed outside VA as permitted by law to include
disclosures as stated in the “Notices of Systems of VA Records” published in the Federal Register in accordance with the Privacy Act of 1974.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond, to this collection of information unless it displays a valid OMB Control Number, The
Privacy Act of 1974 (5 U.S.C. 552a) and VA’s confidentiality statue (38 U.S.C. 5701 as implemented by 38 CFR 1.526 (a) and 38 CFR under any other provision of law. The information
requested is approved under OMB Control Number 2900-0025 and is necessary to ensure that the statutory requirements of the Privacy Act and VA’s confidentially statute are met.
Responding to this collection of information is voluntary. However, if the information is not furnished, we may not be able to comply with your request. Public reporting burden for this
collection of information is estimated to average 7.5 minutes per respondent, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including
suggestions for reducing this burden, to the VA Clearance Officer (045A4, 810 Vermont Avenue, NW, Washington, DC 20420) SEND COMMENTS ONLY. DO NOT SEND THIS FORM
OR REQUESTS FOR BENEFITS TO THIS ADDRESS.
TO
Department of Veterans Affairs
NAME OF VETERAN (Type or print)
SOCIAL SECURITY NO.
NAME AND ADDRESS OF ORGANIZATION AGENCY, OR INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
Office of the Deputy Adjutant General for Veterans Affairs
Attn: Real Estate Tax Exemption
Department of Military and Veterans Affairs
Phone 1-800-547-2838
FTIG, Building S-0-47
Annville, PA 17003-5002
VETERAN’S REQUEST
I hereby request and authorize the Department of Veterans Affairs to
release the following information from the records identified above
to the organization, agency, or individual named hereon:
NAME
Pennsylvania Veterans Affairs (010)
INFORMATION REQUESTED (Number each item requested and give the dates or approximate dates - period from and to - covered by each.)
THIS SECTION TO BE FILLED OUT BY U.S. DEPARTMENT OF VETERANS AFFAIRS
1. Discharged under honorable conditions: Yes No (Circle One)
2. Wartime service: Yes No (Circle One)
3. Does the veteran have a permanent 100% or permanent I.U. Yes No (Circle One)
service-connected disability rating?
4. Does the veteran have any of the following service-connected disabilities:
BLIND – Visual acuity of 3/6 or 10/200 or less. Yes No (Circle One)
PARAPLEGIC –The bilateral paralysis of the upper or lower Yes No (Circle One)
extremities of the body.
AMPUTEE -Loss of two or more limbs. Yes No (Circle One)
5. What was the total amount of compensation the veteran received in the year ________? $______________
6. If the veteran is deceased:
(a) What is the total amount paid the spouse for DIC in the year _________? $______________
(b) Was the veteran rated with a permanent 100% or permanent I.U. prior to death? Yes No (Circle One)
7. Please provide a copy of the veteran’s code sheet.
Signature of US Dept of VA Representative______________________________________________________
PURPOSE (S) FOR WHICH THE INFORMATION IS TO BE USED.
Pennsylvania Veterans’ Real Estate Tax Exemption Program determination
(Veteran Benefit under Title 51, Pa.C.S.)
NOTE: Additional information may be listed on the reverse side of this form.
SIGNATURE OF INDIVIDUAL OR PERSON AUTHORIZED TO SIGN FOR INDIVIDUAL (Attach authority to sign, e.g., POA)
DATE
VA FORM 3288
Department of Veterans Affairs
Form Approved: OMB No. 2900-0025
Respondent Burden: 7.5 minutes
APPLICANT: Fill out sections that are highlighted only
MA-VA 3288 (2019)
all other versions
are obsolete
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DISABLED VETERANS REAL ESTATE TAX EXEMPTION PROGRAM APPLICATION (County of York)

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Completed 18 July 2020

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