New York > Local County > New York > City Of New York > Department Of Finance
Crime Victim-Good Samaritan Exemption Application - New York
| Crime Victim-Good Samaritan Exemption Application Form. This is a New York form and can be used in Department Of Finance City Of New York New York Local County . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
TM Finance Mail to: NYC Department of Finance, P.O. Box 3120, Church Street Station, New York, NY 10008-3120 Instructions: Use this application if you are applying for a partial real property exemption for a disabled crime victim or Good Samaritan who incurred a disability as a result of a crime and has modified a 1-, 2-, 3-family home to accommodate the disability. 1. Owner #1s Name: SECTION I - OWNER INFORMATION CRIME VICTIM/GOOD SAMARITAN EXEMPTION APPLICATION NYC DEPARTMENT OF FINANCE G PROGRAM OPERATIONS DIVISION a. _____________________________________ b. ___________________________________ c. Is this Owner #1s primary residence? FIRST NAME 2. Owner #2s Name: d. Social Security #: K YES e. Date of Birth: K NO LAST NAME MM DD YY a. _____________________________________ b. ___________________________________ c. Is this Owner #2s primary residence? FIRST NAME 2. Borough: ___________ 3. Block #: __________ 4. Lot #:__________ 5. Zip Code: ___________ SECTION III - ELIGIBILITY INFORMATION Law enforcement officers are not eligible for this exemption. 1. Address: a. __________ b. _______________________________________ c. _____________ STREET # STREET NAME APT. # SECTION II - PROPERTY INFORMATION d. Social Security #: K YES e. Date of Birth: K NO LAST NAME MM DD YY 1. Have any owners listed in Section I, their spouses, children, other family members, or non-family occupants been disabled as a victim of a crime or while trying to prevent or assist during a crime ("Good Samaritan")? 3. If you checked "YES" to Question 1 and 2, indicate the cost of the improvements made to the property? 2. If you checked "YES" to Question 1, have improvements been made to the property to accommodate the persons special needs due to the disability? K YES K YES K NO K NO Visit Finance at nyc.gov/finance Crime Victim Ex. Appl. Rev. 08.16.11 American LegalNet, Inc. www.FormsWorkFlow.com $_______________ Crime Victim/Good Samaritan Exemption Application Page 2 SECTION V - SIGNATURES AND CERTIFICATIONS By signing below, I certify that all statements made on this application and attached schedule(s) are true and correct to the best of my knowledge and that I have made no willful false statements of material fact. I understand that this information is subject to audit, and should Finance determine that I do not qualify for tax exemptions, I will be disqualified from future exemptions and will be responsible for all applicable taxes due, accrued interest, and the maximum penalty allowable by law. All owners must sign and date, whether they reside at the property or not. ___________________________________________________ _________/_________/________ OWNERS SIGNATURE DATE Contact Information: If we have a question about this application, whom should we contact? ___________________________________________________ _________/_________/________ OWNERS SIGNATURE DATE Contact Name:___________________________________________________________________ Telephone #: _________________________ Email Address:_____________________________ PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR RECORDS. The Department of Finance will inform you of all exemption benefits that you are eligible for on your Statement of Account. American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
