REQUIRED: 1099-SSA for 2019 & bank statement showing 12/31/19 balance.
Name of Applicant Last, First, Middle Social Security Number Date of Birth
N
ame of Spouse
Last, First, Middle Social Security Number Date of Birth
Pr
operty Address
Street, City, Zip Code Phone Number
A.
Do you live at the above address? ______Yes
_____No If No, list residing address___________________________
B. Mailing Address (if different)
: ________________________________________________________________________
C.
W
aterworks Account Number
: __________________________
D. Were you or your spouse permanently and totally disabled prior to age 65? ____Applicant ____Spouse ____Neither
E. Does anyone other than the applicant and spouse live in the home? _____Yes _____No If Yes, complete section 2.
NAME
SOCIAL SECURITY #
RELATIONSHIP TO OWNER
DATE OF BIRTH
PERSON 1
PERSON 2
PERSON 3
Income From:
APPLICANT
SPOUSE
PERSON 1
PERSON 2
PERSON 3
Wages
$
$
$
$
$
Self Employment
$
$
$
$
$
Unemployment Compensation
$
$
$
$
$
Social Security
$
$
$
$
$
Railroad Retirement
$
$
$
$
$
Non-taxable Veteran’s Benefits
$
$
$
$
$
Military Pensions
$
$
$
$
$
Other Pensions
$
$
$
$
$
Annuity & IRA Disbursements
$
$
$
$
$
Interest
$
$
$
$
$
Dividends
$
$
$
$
$
Rental Income
$
$
$
$
$
Capital Gains
$
$
$
$
$
Gifts/Lottery/ Gambling
$
$
$
$
$
Royalties
$
$
$
$
$
Government Assistance
$
$
$
$
$
Other:____________________
$
$
$
$
$
Other:____________________
$
$
$
$
$
GRAND TOTAL
Total Income:
$
$
$
$
$
$
2. OTHER PERSONS LIVING AT THE ABOVE ADDRESS
Real Estate Acct
#____________________________
N
ame on Deed if different from applicant:
_____________________________
MAILING LABEL
3. TOTAL ANNUAL COMBINED GROSS HOUSEHOLD INCOME JANUARY 1, 2019 TO DECEMBER 31, 2019
FOR OFFICE USE ONLY
Rev 1/16/2020
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 Public________________________________________
Notary registration number _____________________________
SEAL (required) My commission expires ________________________________
APPLICANT SPOUSE
OFFICE USE ONLY
Checking Accounts
$
$
Savings Accounts
$
$
Savings Certificates
$
$
CDs
$
$
Cash Value of Life Insurance
$
$
Stocks
$
$
Bonds
$
$
IRAs/401Ks/Annuities
$
$
Address of other Real Estate:
Thrift Savings Plans
$
$
Other Real Estate (provide address)
$
$
Other:_____________________
$
$
GRAND TOTAL
TOTAL ASSETS:
$
$
$
OTHER ASSETS: Auto, Boat, Camper and similar
Type
Year
Make
Model
Vehicle 1
Vehicle 2
Boat/RV
Trailer/Camper
Other
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
6. AFFIDAVIT
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
click to sign
signature
click to edit
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