NET FINANCIAL WORTH
Does the land on which the residence is located exceed one acre?
If yes, give: Square feet in excess of one (1) acre
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
Certificate of Deposit (CD)
Insurance (Surrender Cash Value)
Real Estate (Other than residence)
Total Combined Net Financial Worth of Owner and Spouse and any Co-owner and Spouse AFFIDAVIT
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.
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 .