Fillable PLEA SE PRINT LEGIBLY MUNIC APPLICATION FOR MUNICIPAL/QUASI-MUNICIPAL (Town Of Bethel, CT)

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PLEA SE PRINT LEGIBLY MUNIC APPLICATION FOR MUNICIPAL/QUASI-MUNICIPAL (Town Of Bethel, CT)

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PLEA
SE PRINT LEGIBLY
MUNIC
IPALITY / QUASI-MUNICIPALITY NAME: ______________________________________________________________
APPLICATION FOR MUNICIPAL/QUASI-MUNICIPAL TAX RELIEF
DEFERRAL PROGRAM UNDER EXECUTIVE ORDER 9R
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 on January, 1, 2021.
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 on
January 1, 2021, be deferred until April 1, 2021 without interest or penalty. Deferral, for purposes of this program, means that
the tax or charge can be paid until April 1, 2021 without interest or penalty.
CHECK P
ROPER ELIGIBILITY:
Resid
ent: 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 October, 2020 to January, 2021 period versus the
Proo
f 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 on January 1, 2021, be deferred until April 1, 2021 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 forbea
rance, for purposes of this program, means either a) a deferral of 25% of rent (approximating
the property tax portion of rent) f
or 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.
October, 2019 to January, 2020 period.
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
January 1, 2021 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) on or before April 1, 2021 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.
(E) My
financial i
nformation is being provided in confidence and I request that the information contained in this application
not be disclosed to the extent allowed by state law. I understand that the Freedom of Information Act Section 1-210(b)(5)
(B) allows, but does not require, a public agency to withhold records that constitute commercial or financial
information given in confidence, not required by the Connecticut General Statutes.
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.
SIGNATURE OF APPLICANT
X
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,
Revised 12/2
020
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PLEA SE PRINT LEGIBLY MUNIC APPLICATION FOR MUNICIPALQUASI-MUNICIPAL (Town Of Bethel, CT)

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Completed 22 January 2021

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