Page 2 of 2 RP-467-Rnw (2022)
3a Total income of owner(s) and spouse(s)
(add all income sources) .......................................... 3a
3b Of the income on line 3a, 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 0 if not applicable
(see instructions) ..................................................................................................................... 3b
3c Subtract line 3b from line 3a ................................................................................................ 3c
4 If a deduction for unreimbursed medical and prescription drug expenses is authorized by
any of the municipalities in which property is located (contact assessor for information),
complete the following:
4a Unreimbursed medical and prescription drug costs
(be sure to deduct any amounts
reimbursed by insurance) ......................................................................................................... 4a
4b Subtotal income of owner(s) and spouse(s) (line 3c minus line 4a) ................................... 4b
5 If a deduction for veteran’s disability compensation is authorized by any of the municipalities
in which the property is located, complete the following:
Veteran’s disability compensation received. Attach proof; enter 0 if not applicable ................. 5
6 Total income of owner(s) and spouse(s) (line 4b subtotal minus line 5) ..................................... 6
7 Certication
I (we) certify that all statements made on this application are true and correct to the best of my (our) belief. I (we) understand that
any willful false statement of material fact will be grounds for disqualication from further exemption for a period of ve years, and a
ne of not more than $100.
Signature
(If more than one owner, all must sign)
Marital status Phone number Date
This Area for Assessor’s Use Only
Assessor’s signature Date
Date renewal application led Approved Disapproved
Reason for denial
Exemption applies to taxes levied by or for: City/Town % County %
School % Village %
Names of owner(s) and spouse(s) Source of income Amount of annual income
3 Provide the income of each owner and spouse of each owner for the applicable income tax year, except for an owner who is absent
from the residence due to divorce, legal separation, or abandonment. Attach additional sheets if necessary. See Form RP-467-I to
determine the applicable income tax year and the income to be included.