RP-459-c-Rnw (9/09)
NEW YORK STATE DEPARTMENT OF TAXATION & FINANCE
OFFICE OF REAL PROPERTY TAX SERVICES
RENEWAL APPLICATION FOR PARTIAL TAX EXEMPTION
FOR REAL PROPERTY OF PERSONS WITH DISABILITIES
AND LIMITED INCOMES
APPLICATION MUST BE FILED WITH YOUR LOCAL ASSESSOR BY TAXABLE STATUS DATE
Do not file this form with the Office of Real Property Tax Services.
General information and instructions for completing this form are contained in RP-459-c-Ins
1. Name and telephone no. of owner(s) 2. Mailing address of owner(s)
________________________________________
________________________________________
Day No. ( ) ___________________________
Evening No. ( ) _______________________ E-mail (optional)
3. Location of property (see instructions):
Street address
City/Town Village (if any)
School District
Property identification (see tax bill or assessment roll)
Tax map number or section/block/lot
4. Description of nature of applicant’s physical or mental impairment which currently substantially limits one or
more major life activities (e.g. walking)
5. Indicate documents submitted with previous application as proof of disability unless proof of permanent
disability was submitted in a previous year.
Proof of permanent disability submitted in previous year
Award letter from Social Security Administration of entitlement to social security disability
insurance (SSDI) or supplemental security income (SSI)
Award letter from Railroad Retirement Board of entitlement to railroad retirement disability benefits
Certificate from State Commission for the Blind and Visually handicapped stating that applicant
is legally blind
Award letter from United States Postal Service certifying disability pension
Award letter from United States Department of Veterans Affairs certifying disability pension
6. Do all the owners of the property presently reside on the premises? Yes No
If answer to 6 is No, is an owner receiving medical care as an in-patient in a residential health care facility?
Yes No
If answer is Yes, specify name and location of the facility
7. Is any portion of the property used for other than residential purposes (farming, commercial, vacant land,
professional office, etc.)? Yes No
If answer is Yes, explain such use and describe the portion that is so used.
8. Income of each owner and resident spouse of each owner for the calendar year immediately preceding date of
application MUST be set forth on next page (attach additional sheets if necessary).
RP-459-c-Rnw (9/09)
2
Name of owner(s) Source of income Amount of income
Name of spouse(s) if Source of income Amount of income
not owner of property of spouse(s) of spouse(s)
Subtotal income of owner(s) and spouse(s) $
9. Of the income specified in #8 how much, if any, was used to pay for an
owner’s care in a residential health care facility?
(Attach proof of amount paid: enter zero if not applicable.) $
(#8 minus #9) $
10. If a deduction for unreimbursed medical and prescription drug expenses
is authorized by any of the municipalities in which property is located
complete the following:
(a) Medical and prescription drug costs; $
(b) Subtract amount of (a) paid or reimbursed by insurance: $
(c) Unreimbursed amount of (a) (attach proof of expenses and
reimbursement, if any; enter zero if option not available): $
Total income of owner (s) and spouse (s) [#9 minus #10 (c)] $
11. Did the owner or spouse file a federal or New York State Income Tax return for the preceding year?
Yes No If answer is Yes, attach copy of such return or returns.
12. Does a child (or children), including those of tenants or lessees, reside on the property and
attend a public school, grades K through 12? Yes No
If Yes, show name and location of school(s): ___________________________________________________
________________________________________________________________________________________
If Yes, was the child (or were the children) brought into the residence in whole or in substantial part for the
purpose of attending a particular school within the school district? Yes No
I certify that all the statements made on this application are true and correct.
Signature Marital Status Phone No. Date
(If more than one owner, all must sign.)
___________________________________ _____________________ __________________ __________________
___________________________________ _____________________ __________________ __________________
SPACE BELOW FOR USE OF ASSESSOR
Date application filed ____________________ Exemption applies to taxes levied by or for:
Application approved Town School
Application disapproved Village County
____________________________________________
Assessor’s signature Date
Clear Form