Yes
Yes No
Yes No
Yes No
Date
Date
Need Assistance?
Phone: 540-382-5710
Fax: 540-381-6838
Application
Real Property Tax Relief
For Veterans With
100% Service-Connected Disability
Helen P. Royal, MCR
Master Commissioner of the Revenue
755 Roanoke St. Suite 1A
Christiansburg, VA 24073
Name (Applicant/Owner):
Social Security #:
Phone #:
Applicant Information
best of my (our) knowledge and belief is true, correct, and complete.
Certification from U.S. Department of Veteran Affairs of 100% Service Connected Disability attached or on file
with Commissioner of the Revenue
Is this property occupied as the principal residence by the qualifying veteran?
Is this property jointly owned by the applicant and spouse?
(if no please describe ownership arrangement)
Privacy Act Notice:
Disclosure of your social security number on this form is mandatory, as authorized by the
Virginia State Code Section 58.1-3017. Social Security numbers are regarded as confidential, and except as
otherwise provided by law, will not be disclosed for any other purpose.
I (we) declare, under penalties provided by law, that this certification has been examined by me (us) and to the
Name (Co-Owner/Spouse):
Social Security #:
Phone #:
Property Address:
Mailing Address (if different than Property Address):
Certifications
Signature of Applicant/Owner
Signature of Co-Owner/Spouse
Signature of Preparer (if not applicant)
Relationship
Daytime Phone Number
2021
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
.
.
.
.
.
.
.
Exempted
Taxable
Total Value
Tax Rate
Total Taxes
Amount of Relief
Entry Year:
Acreage:
If no, explain why:
Land Value
Building Value
(If applicable) Copy of Veteran's death certificate showing death occurred on or after January 1, 2011.
Pursuant to Article X, Section 6-A of the Constitution of Virginia, the General Assembly exempted from taxation the real property, including
the joint real property of husband and wife, of any veteran who has been rated by the U.S. Department of Veterans Affairs or its successor
agency pursuant to federal law to have a 100 percent service-connected, permanent and total disability, and who occupies the real property as
his principal place of residence.
The surviving spouse of a veteran eligible for the exemption set forth in this article shall also qualify for the exemption, so long as the death
of the veteran occurs on or after January 1, 2011 and the surviving spouse does not remarry.
The veteran or surviving spouse claiming the exemption under this article shall file with the Commissioner of the Revenue an affidavit or
written statement ( i ) setting forth the name of the disabled veteran and the name of the spouse, if any, also occupying the real property, ( ii )
indicating whether the real property is jointly owned by a husband and wife, and ( iii ) certifying that the real property is occupied as the
veteran's principal place of residence. The veteran shall also provide documentation from the U.S. Department of Veterans Affairs or its
successor agency indication that the veteran has a 100 percent service-connected, permanent, and total disability. The veteran shall be
required to re-file the information required by this section only if the veteran's principal place of residence changes. In the event of a
surviving spouse of a veteran claiming the exemption the surviving spouse shall also provide documentation that the veteran's death occurred
on or after January 1, 2011.
OFFICE USE ONLY
Owner of Record:
Residence must be Veteran's primary residence (proof, such as resident State tax return, may be requested).
Spouse (if applicable) must also be identified.
Deceased Veteran (if applicable) must have died on or after January 1, 2011.
Surviving Spouse (if applicable) must not be remarried.
Certification of disability being: (a) 100% service-connected, AND (b) permanent, AND (c) total.
PIN:
IMPORTANT INFORMATION
QUALIFICATIONS:
REQUIRED DOCUMENTATION:
Disability of Veteran must be 100% service-connected AND permanent AND total.
Qualifies? Yes No