LONG FORM: PROPERTY TAX EXEMPTION FOR SENIORS
1. Identification of Applicant and Property
Applicant's First Name, Middle Initial and Last Name Property Address (number & street name) City or Town Mailing Address (if different than property address) State
County Name Address Address Phone Number and Fax Number
Social Security No.
Date of Birth
Schedule or Parcel Number Zip Code Telephone Number Check Box if Ownership is Held in a Life Estate.
2. Age and Occupancy Requirements (One of the following statements must be true.)
2A. As of January 1 of this year, I am 65 years old, and I occupy the property listed above as my primary residence. I have occupied it as my primary residence for at least 10 consecutive years prior to January 1 of this year. True 2B. I am the surviving spouse of an individual who previously qualified for the exemption. Each of the following statements is true. a) My spouse passed away after December 31, 2001; and b) My spouse was at least 65 years old on January 1 of the year he or she passed away; and c) My spouse occupied the property as his or her primary residence for at least 10 consecutive years prior to January 1 of the year he or she passed away; and d) I occupied the property with my spouse as our primary residence; and Date of birth of spouse e) I currently occupy the property as my primary residence; and who previously qualified f) I have not remarried. Each one of statements a) through f) is true. True 2C. If not for the fact that either I or my spouse was confined to a health care facility, or our prior residence was condemned in an eminent domain proceeding, one of the statements above would be true. 1) Statement #2A would be true 2) Statement #2B would be true (If #2A or #2B would be true, you must complete either section #5 or section #6 on the back of this form.)
3. Ownership Requirement (One of the following statements must be true.)
3A. The owner of record for the property described above is either a) me, b) my spouse, or c) both of us. The property has been owned by one or both of us for at least 10 consecutive years prior to January 1 of this year. During periods when the property was owned by my spouse and not by me, my spouse and I were married and my spouse occupied the property as his or her primary residence. True 3B. Statement #3A would be true if not for the fact that ownership has been transferred to a trust, corporate partnership or other legal entity solely for estate planning purposes, or my/our prior residence was condemned in an eminent domain proceeding. True (If #3B is true, complete either section #7 or section #8 on the back of this form.)
4. List each additional person who occupies the property as his or her primary residence.
4A. Person who also occupies property as primary residence 4B. Person who also occupies property as primary residence 4B. Person who also occupies property as primary residence Spouse Yes No Social Security Number Social Security Number Social Security Number
5. Complete this section if applicant or spouse was/is confined to a nursing home, hospital, or assisted living facility.
5A. Name of Confined Individual 5B. Location 5C. Dates Confined
5D. During confinement, the property was occupied by either a) the spouse of the person confined, b) a financial dependent, or c) the property remained unoccupied. True
6. Complete this section if prior residence was condemned in an eminent domain proceeding.
6A. Street address of condemned property 6C. Dates condemned property was occupied as primary residence 6B. Dates of ownership of condemned property from: to: 6D. Approximate date of condemnation
6E. Since condemnation, I have not owned and occupied any property as my primary residence other than the property for which I am applying for exemption. True 6F. If condemnation of the prior residence had not occurred, the condemned property would still be my primary residence. True
7. Complete this section if property is owned by a trust or an individual as trustee.
7A. Name of Trust 7B. Maker(s) of Trust 7D. Beneficiary 7D. Beneficiary 7C. Trustee 7D. Beneficiary 7D. Beneficiary
7E. The property was transferred to the trust solely for estate planning purposes. Had the property not been transferred, I and/or my spouse would be the owner(s) of record. True
8. Complete this section if property is owned by a corporate partnership or other legal entity.
8A. Name of Corporate Partnership or Legal Entity 8B. Name of Principal 8B. Name of Principal 8B. Name of Principal 8B. Name of Principal
8C. The property was transferred to the corporate partnership or legal entity solely for estate planning purposes. Had the property not been transferred, I and/or my spouse would be the owner(s) of record. True
9. Affidavit and Signature
I declare, under penalty of perjury in the second degree (§ 18-8-503, C.R.S.), that the information provided on this form and on any attachments is correct. Signature:____________________________________________________________ Signer is: Applicant Spouse Guardian* * Authorization in the form of a court order or power of attorney is required. Other Contact:_____________________________________________________ (relative, personal representative, etc.) Telephone Number:__________________ Date:_________________ Conservator* Attorney-in-fact*
The County Assessor must be informed of any change in ownership or occupancy of the property within 60 days of such occurrence. Mail, FAX, or deliver this form to your County Assessor by July 15. We recommend you obtain a receipt when delivering the form in person, or mail the form by certified mail. You may also call the Assessor to ensure that your application was received.