Free Surviving Spouses of Disabled Veterans Receiving - Maryland

STATE OF MARYLAND

RETURN TO:
Your local Assessment Office. Click this box to get a list of local offices.

DEPARTMENT OF ASSESSMENTS AND TAXATION APPLICATION FOR EXEMPTION FOR SURVIVING SPOUSES OF DISABLED VETERANS RECEIVING DIC BENEFITS

To be filed with the Supervisor of Assessments in the appropriate local office.

This form seeks information for the purpose of an exemption for the surviving spouse of a disabled veteran on the indicated property. Failure to provide this information will result in denial of your application. However, some of this information would be considered a "personal record" as defined in State Government Article, §10-624. Consequently, you have the statutory right to inspect your file and to file a written request to correct or amend any information you believe to be inaccurate or incomplete. Additionally, personal information provided to the State Department of Assessments and Taxation is not generally available for public review. However, this information is available to officers of the State, county or municipality in their official capacity and to taxing officials of any State or the federal government, as provided by statute. Additionally, if your property would be used by the State Department of Assessments and Taxation as a comparable for purposes of establishing the value of another property in a hearing before the Maryland Tax Court, the requested information, or a portion thereof, may have to be provided to the owner of that other property.

Full Name of Titled Owner: Address of Property:

__________________________________________________________________

___________________________________________________________________

Description/Location of Property __________________________________________________________________ Account Number: ___________________________________
Baltimore City Counties Ward District Section Map Block Block Lot Parcel

Date Acquired: ____________________________

Deed Reference: _____________________________

Subdivision: ______________________________________________________________________ Name of Veteran: ______________________________________________________________________ Social Security Number ___________________________ Claim number_____________________________ Date of Veteran's Death _________________________
*Attach a copy of a Veteran's Honorable Discharge or a Copy of DD-Form No. 214 as Required by Law. (Tax-Property Article §7-208). I declare under the penalties of perjury, pursuant to Section 1-201, Tax Property Article, of the Annotated Code of Maryland, that this return (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete return and that I am the unremarried spouse of the veteran. In affixing my signature to this application, I hereby grant permission to the Veteran Affairs (VA) to release to the Department the medical and other record information requested below.

_________________________________________ _____________________
Signature of Surviving Spouse Phone

___________________
Date

____________________________________________ ___________________________________________________________ Address City State Zip Code

THIS APPLICATION IS NOT OPEN FOR PUBLIC INSPECTION

SDAT ­ 4B1 (10/08)

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SDAT APPLICATION FOR EXEMPTION FOR SURVIVING SPOUSES OF DISABLED VETERANS RECEIVING DIC BENEFITS (continued)

TO BE COMPLETED BY THE VETERANS ADMINISTRATION
The United States Department of Veteran Affairs (VA) hereby certifies that the above named veteran: (1) Prior to his/her death, was declared by the VA to have a service-connected disability, which was not incurred through misconduct. Yes ____ No ____. If yes, the said disability was _______% disabling, permanent in character, and reasonably certain to have continued throughout the life of said veteran; and that the said veteran had been receiving disability payments as allowed for reasons of _______% disability, or _______% unemployability. (2) (3) After his/her death, was the veteran declared by the VA to be 100% disabled? Yes ____ No __

Is the veteran's surviving spouse receiving Dependency and Indemnity Compensation (DIC) from the VA? Yes ____ No ____

(4) Specify the nature of the service connected disability or illness of the veteran that entitles the surviving spouse
to receive DIC:

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
_________________________________ Effective Date ___________________________________________ Address ___________________________________________ Phone _______________________________________________ Adjudication/Service Officer _____________________________________________ City State Zip Code _____________________________________________ Date

(FOR SDAT OFFICE USE ONLY) COMMENTS: _______________________________________________________________________________________ _______________________________________________________________________________________ New Application Approved



Re-application Disapproved



Code No. ___________________ Effective: ____________________
Total ___________________

Land _________________

Improvement _________________

_________________________________________________ Supervisor's Signature

___________________________________ Date

THIS APPLICATION IS NOT OPEN FOR PUBLIC INSPECTION

SDAT ­ 4B1 (5/09)

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