I hereby request real estate tax deferral and certify the foregoing statements are true and correct to the best of my
knowledge and belief. I understand any person falsely requesting tax deferral shall be guilty of a Class 3
misdemeanor. I agree to notify the Office of the Commissioner of the Revenue immediately if any changes occur with
respect to my income, financial worth, or ownership of the property.
I understand if I am eligible, my real estate tax for 2020-21 will be deferred and the accumulated amount of taxes
deferred shall be paid to the city treasurer immediately upon the sale or transfer of title of the dwelling or shall be paid
from the estate of the decedent within one (1) year after the death of the last owner who qualified for tax deferral.
City/County of ________________________
Commonwealth of Virginia
The foregoing instrument was subscribed and sworn before me this ____day of ___________________, 2020
by _____________________________________ in the city/county and state aforesaid.
(name of applicant)
Notary registration number _____________________________
SEAL (required) My commission expires ________________________________
OFFICE USE ONLY
Cash Value of Life Insurance
Address of other Real Estate:
Thrift Savings Plans
Other Real Estate (provide address)
OTHER ASSETS: Auto, Boat, Camper and similar
If eligible for deferral, do you elect to defer 100% of your 2020-21 real estate tax? YES_______ NO _______
If NO, indicate the percentage of your real estate tax you elect to defer . ________%
IMPORTANT! You will be billed and must pay the balance of the 2020-21 tax that you elect not to defer.
4. ASSETS – BALANCES OF ACCOUNTS OR VALUES OF ASSETS ON DECEMBER 31, 2019
Applicant’s Signature Date
In order for your application to be processed, you must complete all sections of this application, sign on the applicant signature line in the
presence of a notary public, and the notary public must complete and sign in the space provided below. Please be advised submission of an
incomplete application may result in your application being denied.
5. ELECTION OF DEFERRAL AMOUNT
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