ELIGIBILITY REQUIREMENTS
TAX RELIEF FOR THE ELDERLY AND/OR DISABLED PROGRAM
FOR REAL ESTATE/MOBILE HOME OWNERS

COUNTY OF YORK, VIRGINIA

 PLEASE READ CAREFULLY BEFORE FILLING OUT APPLICATION

         The applicant(s) must be a homeowner in York County, Virginia and live in the dwelling for which
         the affidavit is being made for tax relief.

         MINIMUM AGE - ELDERLY : 65 (as of December 31^st of the previous tax year)   
         MINIMUM AGE - DISABLED: NONE

         DISABLED STATUS:

• Definition: Permanently and totally disabled and is unable to engage in any substantial
  gainful activity by reason of any medically determined physical or mental impairment or
  deformity which can be expected to last for the duration of such person's life.

• To qualify you must have certificates or letter(s) stating total and/or permanent disability
  from one of the following:
                 -Two affidavits/letters from different medical doctors who have a license to practice
                  medicine in Virginia; OR
                 -Certification by the Department of Veteran Affairs; OR
                 -Certification by the Railroad Retirement Board; OR
                 -Letter from the Department of Social Security
  
  GROSS INCOME: Section D Line 1 through Line 6 of the application- Based on the total
  maximum combined gross income of previous year.
  
  INCOME TAX: PLEASE FILE YOUR INCOME TAXES BEFORE YOU SUBMIT THE APPLICATION.

• If you or any one in your household is required to file a FEDERAL INCOME TAX RETURN (Forms
  1040/1040A), a copy must be submitted along with the application.

• Each individual must submit a copy of the Annual Social Security Statement/Annuity Statement, W-2(s),
  1099(s), and any other statement providing  the source of income, along with the application.
                                                     

    GROSS INCOME GUIDELINES*  


1 Eligible Owner                2 Or More Eligible Owners             Exemption
               (household income)                 (household income)                        Amount                   
$39,851   - $50,000/YR         $40,785    - $50,000/YR                    Up to $300.00
 $29,701  - $39,850/YR          $31,568    - $40,784/YR                    Up to $420.00
 $19,551   - $29,700/YR         $22,351    - $31,567/YR                    Up to $600.00
 $19,550  - and Under            $22,350  - and Under                                  100%  
 

           *All income should be reported for each individual in the household. This office will consider all
            exemptions allowed by County Code.

           FINANCIAL WORTH/ASSETS: Section E Line 1 through 8 of the application

• Guideline- To qualify your combined maximum financial worth (or assets) must not exceed $200,000,
  EXCLUDING the value of this dwelling & up to TEN (10) acres of land.

• Each individual must provide a copy of statements from each financial institution (checking, saving,
  stocks/mutual funds, certificate(s) of deposit, etc.)

• Line 3- This office will calculate the value of each car, truck, boat, trailer, camper, and motor home(s)

Line 7- Provide the description of all real estate owned, or you have an interest in (do not include your
residing home)

A new application must be filed each year. Applications will be available to the public January of each
year.
The DEADLINE FOR FILING IS APRIL 1.
Changes in income, financial worth, ownership or other factors affecting the qualification for relief must be reported immediately to the office of the Commissioner of the Revenue.
            ______________________________________________________________________________
                                                       
                                                         2008
                       Application for Tax Relief for the Elderly and Disabled
                                     Real Estate/Mobile Home Owners
                               Must be filed by April 1st annually

APPLICATION FOR: Real Estate Owner(s)    Mobile Home Owner(s)

Check Type of Relief: Age 65 and Older     Permanently and Totally Disabled
Effective Date of Disability:

Applicant/Owners Name:
(Last)   (First)   S.S. No.
Co-Owners/Spouse Name:
(Last)   (First)   S.S. No.
Mailing Address:
Street Address/P. O. Box #
City State   Zip Phone #
Owners Date of Birth Co-Owners Date of Birth
Age of Owner     Age of Co-Owner

Do you have a relative living with you to provide care because it is the only alternate
to permanently residing in a hospital, nursing home, convalescent home or other
facility for physical or mental care? Yes     No

If Yes, provide name(s), relationship, and Social Security Number:

(You may be required to provide clear and convincing evidence that your physical or mental
health has deteriorated to the point that it is necessary to have a relative move in and provide
care.)

Is this property occupied by the applicant as the sole dwelling? Yes    No

If No, explain the location of your sole dwelling and the circumstance that make you live elsewhere:
 

Is this property used by or leased to others for consideration?  Yes    No

If Yes, provide detailed explanation:
 

List Names of all persons (other than the owners listed above) who live in the household:

***IMPORTANT***-You must answer the following question:

Have you transferred money, assets or property in excess of $10,000 to anyone within the past 3 years?
Yes    No

If Yes, provide the name of person(s), relationship, description of property, amount and date of transaction.

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, those numbers will not be disclosed for any other purpose.

COMBINED INCOME STATEMENT WORKSHEET
You must provide information from ALL sources

Were you, your spouse, care giver, or relative(s) living in your household, required to file a Federal Income Tax
Return, or State Income Tax Return? Yes    No

If Yes, you must provide a copy of the complete 2007 tax return(s) including all W-2(s), 1099(s) and schedules.

If No, you must sign this space attesting to the fact that 2007 tax return(s) were not required to be filed:
Initials of Applicant/Owner        Initials of Applicant/Co-Owner   

COMBINED FINANCIAL WORTH
You must provide a statement of your financial worth for the calendar year ending December 31, 2007
DO NOT ESTIMATE-Submit a copy of the statement from each financial institution(s)

Is this the first time you have applied? Yes     No

For your FIRST time filing as DISABLED, you must furnish a certificate from the Department of Veteran Affairs, the Railroad Retirement Board, or Social Security Administration. If you are not disabled through those entities, you MUST furnish certificate(s) or letter(s) from two (2) medical doctors licensed to practice medicine in Virginia.

You must complete all spaces on this entire application. If not applicable, put "N/A"  or "$0.00". Failure to complete the entire application and provide supporting documentation will jeopardize the approval process of your application.

Provide name, address, and phone number of a relative or friend whom we may contact regarding your affidavit in the event we are unable to reach you at the above address or phone number.
Name: (Last)    (First)   
Street Address/ P. O. Box #
City   State   Zip Phone #
Relation to you   

I (we), certify under penalty of law that I (we) have prepared or examined this affidavit and to the best of our knowledge and believe it is true, correct and complete.

Owner's Initials         Date      Co-Owner's Initials         Date  

Preparer's Initials (If not applicant)         Date      Phone Number

Email Address

Note: Any changes in income, financial worth, ownership of property or other factors affecting the
         qualifications for relief must be reported IMMEDIATELY to the Office of the Commissioner
         of the Revenue (757) 890-3382.
       
                                            *** You may wish to print a copy for your records***