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Case Number

Portsmouth Department Of Social Services 1701 High Street Portsmouth, VA 23704-3100

Date Received

Interviewed by ___________________

Tracked

yes

no

APPLICATION FOR REAL ESTATE TAX RELIEF FOR PERSONS AGE SIXTY-FIVE OR OLDER OR PERMANENTLY AND TOTALLY DISABLED

INSTRUCTIONS TO APPLICANT

The information required on this application must be filled out in its entirety and returned to the Department of Social Services, 1701 High Street, Portsmouth, Virginia 23704-3100. Spaces on the application that are not applicable to the taxpayer should be completed as “Not Applicable” or “$0.00” as indicated by the question. Questions that cannot be answered within the spaces provided can be answered by attaching additional sheets to this application. THIS TAX RELIEF IS GRANTED ON AN ANNUAL BASIS AND A NEW APPLICATION MUST BE COMPLETED EACH YEAR. All information on the application is confidential and not open to public inspection. For additional information, please phone 405-1800. If possible, please attach a copy of your most recent federal income tax return to the affidavit. THIS APPLICATION MUST BE NOTORIZED. A Notary Public is available during office hours at the Department of Social Services, 1701 High Street, Suite 101.

To be completed by the Tax-Payer as shown on the tax bill Description of Property

Map:

Parcel:

A.

IDENTIFYING INFORMATION

1.

Applicant: (Property Owner)

Last Name

First

Middle

2.

Birth Date:

3.

Spouse:

/

/

Month/Day/Year

/

Social Security No.

Phone

Last Name

First

Middle

4.

Birth Date:

//

/

Social Security No.

Phone

Month/Day/Year

5.

Residence Address:

Street No.

Street

City, Town, or Post Office

State

Zip Code

6.

Mailing address if it is different from the residence address

Street No.

Street

City, Town, or Post Office

State

Zip Code

7.

Name under which property is listed and appears on the tax bill, if different from the applicant or spouse’s name:

Name:

8. Co-Owner:

Last Name

First

Middle

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