X hits on this document

17 views

0 shares

0 downloads

0 comments

4 / 5

D.

NET FINANCIAL WORTH

1.

Does the land on which the residence is located exceed one acre?

(

) Yes

(

) No

If yes, give: Square feet in excess of one (1) acre

2.

Please complete this statement of financial worth as of December 31. Net financial worth is computed by subtracting liabilities from assets. Included in this statement must be the net financial worth, including equitable interests, of the owner (applicant) and his spouse, and of any co-owner and his spouse. Exclude the value of the applicant’s residence and up to one (1) acre of land upon which the residence is situated. (Attach additional sheet if necessary).

NET VALUE OF ASSETS AS OF DECEMBER 31, 2010

OWNER SPOUSE CO-OWNER

SPOUSE

Automobile

Automobile

Bonds

CAP Account

Certificate of Deposit (CD)

Checking Account

Insurance (Surrender Cash Value)

Interest

IRA

Mutual Funds

Real Estate (Other than residence)

Savings Account

Stocks

Other Assets

TOTALS

Total Combined Net Financial Worth of Owner and Spouse and any Co-owner and Spouse AFFIDAVIT

$

COMES NOW

of legal age, having first sworn and on-oath state the

foregoing statements are true and accurate to the best of my knowledge and belief, and I understand that any factors occurring during the

taxable year for which this affidavit is filed that have the effect of exceeding or violating the limitations and conditions provided by the ordinance shall nullify any exemption for the current taxable year and the taxable year immediately following. Any person or persons falsely claiming an exemption shall be guilty of a misdemeanor and upon conviction thereof shall be punished by a fine not exceeding $1, 000.00, or confinement in jail not exceeding twelve months, or both.

I have read the foregoing affidavit and swear that its contents are true to the best of my knowledge and belief.

Signature

STATE OF VIRGINIA CITY OF PORTSMOUTH, to wit:

Personally appeared before me in my county and state aforesaid who being first duly sworn by me acknowledged the signature to the foregoing affidavit to be his own and state on information and belief that the said statements are true and correct.

Subscribed and sworn to before me the undersigned Notary Public in my city and state aforesaid the .

day of

, 20

Notary Public

Document info
Document views17
Page views17
Page last viewedMon Dec 05 12:06:01 UTC 2016
Pages5
Paragraphs169
Words997

Comments