county of prince william - Prince William County Government

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4379 Ridgewood Center Drive, #203, Prince William, Virginia 22192. Real Estate ... NET FINANCIAL WORTH AS OF DECEMBER 31, 2015. Do not include the ...
2016 TAX RELIEF APPLICATION

COUNTY OF PRINCE WILLIAM

RENEWAL APPLICANTS ONLY

4379 Ridgewood Center Drive, #203, Prince William, Virginia 22192 Real Estate Assessments Office (703) 792-6780 Metro 631-1703 ext. 6780 RENEWAL APPLICATION FOR RELIEF OF 2016 REAL ESTATE TAXES AND/OR VEHICLE LICENSE FEE AND PERSONAL PROPERTY TAX FOR CITIZENS AGE 65 OR OLDER AND PERSONS WHO ARE TOTALLY AND PERMANENTLY DISABLED.

NAME & ADDRESS:

INSTRUCTIONS TO APPLICANT: This application must be filled out completely and returned to the Real Estate Assessments Office. Applications should be filed by April 15, 2016. ** You must reapply every year.

PHONE NUMBER:

SOCIAL SECURITY NUMBER:

PLEASE CHECK ALL THAT APPLY  65 years or older

or

 Totally and permanently disabled

 Relief of real estate taxes

or

 Relief of mobile home taxes

 Relief of personal property tax and vehicle license fee

Vehicle(s) previously applied New Vehicle

Year

Make

Model

Title Number

COMPLETE BOTH SECTIONS ON BACK

******OFFICE USE ONLY ****** TOTAL INCOME NET WORTH ACCOUNT / ACREAGE NON QUALIFYING ASMT. RE REVIEWED BY: ________________________

APPROVED 

PP

MH NOT APPROVED 

Rev: 20151207

TOTAL INCOME FOR CALENDAR YEAR 2015 Include the total income from all sources of the applicant, spouse and all persons related to the applicant living in the residence. Capital gains are any gains from the sale of an asset whether or not it was taxable. Total Income

APPLICANT

(Before deductions)

SPOUSE

Relatives other than Spouse

TOTAL

Salaries & Wages Pensions All Social Security Income Disability Income Interest & Dividends Welfare & Gifts Capital Gains IRA Distributions Other Income Next Two Lines For Office Use Only

Deduction Total Income

NET FINANCIAL WORTH AS OF DECEMBER 31, 2015 Do not include the value of the house on which you are seeking relief or the mortgage against it. NET VALUE OF ASSETS

APPLICANT

SPOUSE

TOTAL

Personal Property (vehicles) Savings Account(s) Checking Account(s) Stocks and Bonds IRA(s) Other Real Estate Other Assets/CDs Total Assets Liabilities* Net Financial Worth

* Liabilities do not include the mortgage on the house on which you are seeking relief or credit card debt. APPLICATION MUST BE SIGNED, BUT DOES NOT NEED TO BE NOTARIZED. I (we) do swear or affirm that the statements and figures contained in this application are true, full and correct to the best of my (our) knowledge and belief, and I (we) understand that any factors occurring during the taxable year for which the affidavit is filed that will result in exceeding or violating the limitations and conditions provided by Chapter 26 of the Code of Prince William County, Virginia, shall disqualify me (us) for the current taxable year and the next taxable year.

__________________________ (Owner’s Signature)

__________________________ (Co-Owner’s Signature)

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