SENIOR PROPERTY VALUATION PROTECTION OPTION
INITIAL APPLICATION
NOTICE OF REAPPLICATION
APPLICANT: Please read the instructions on the reverse side before completing this form. Complete the form and
copy for your records before submitting it to the County Assessor where your primary residence is located. The form
must be submitted by September 1.
Application Date _________ County _____________ Parcel ID Number _____________ Account Number _____________
Applicant’s Name(s) ______________________________________ / __________________________________________
Primary Residence Address ___________________________________________ City ______________ Zip ___________
Years lived in primary residence _________ (must be minimum of two years). Provide proof of residency by submitting
utility statements, voter registration, or other documentation of proof as requested by the Assessor.
NOTE: “Primary residence” as defined in Article 9 Section 18 of the Arizona Constitution means all owner occupied real property
and improvements to that real property in this state that is a single family home, condominium or townhouse or an owner occupied
mobile home and that is used for residential purposes. A qualified taxpayer can have only one primary residence.
Are you the sole owner? Yes No If co-owned, please state total number of owners ___________________
At least one of the owners must be sixty-five years old. Provide proof of age (birth certificate, driver’s license, passport, etc.).
Qualified Owner’s date(s) of birth: _____-_____-_____ / _____-_____-_____
INCOME INFORMATION: List total annual income for all owners from all sources, taxable and non taxable, for
the previous three calendar years. Documentation may be requested by the Assessor to verify income.
INCOME FROM ALL SOURCES Year One _______ Year Two _______ Year Three ______
Salaries, wages, and tips earned. $ $ $
Social Security benets received.
Pension and annuity income received.
Dividend and interest income received.
Rent and royalty income received.
Business and farm income received.
Unemployment insurance payments received.
Workmen‘s compensation payments received.
Railroad retirement benets received.
Veteran’s disability pension payments received.
Alimony payments received.
Estate and trust income received.
Public Assistance payments received.
Other income earned or received.
TOTAL ANNUAL COMBINED INCOME = $ $ $
Three Year Total Annual Combined Income $ ___________________ Three Year Average $ _________________
Under penalty of perjury, I/we hereby certify that all of the information contained in this application form is true and correct.
I/we consent to the freezing of the valuation of my primary residence for a three year period.
Print Name(s) ________________________________ / ______________________________ Phone ________________
Signature(s) _________________________________ / ________________________________ Date ________________
THIS BLOCK IS FOR COUNTY ASSESSOR USE ONLY
Residency/Age/Income Requirements Met? Yes No
Limited Property Value Freeze Approved Yes No
Amount of Three Year Average Income Veried $ _____________ Assessor/Deputy _______________ Date __________
Valuation Protection Option applied to valuation years ________, ________ and ________.
DOR 82104 (Revised 01/2020)
YELLOW fields are Read-Only. You can not enter data in yellow fields.
These fields are calculated as you fill in the form.
