Tax Credit Application and Affidavit

Tax Credit Application and Affidavit

Disabled Law Enforcement Officer Application
PLEASE READ THE ATTACHED ORDINANCE,
WHICH IS THE BASIS FOR DETERMINING ENTITLEMENT TO THE TAX CREDIT.

PLEASE ATTACH TO YOUR APPLICATION:

1. A copy of the determination of disability

2. A copy of the deed to the property

3. For spouses and cohabitants, a copy of the death certificate.

Please use the upload button found at the end of this form.
Date Application Filed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name(s) of Property Owner(s):
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Tax Account Number:
Deed Reference:
Liber:
Folio
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Property Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Address of the disabled law enforcement officer or rescue worker on the date that he or she died or was adjudged to be permanently and totally disabled:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of death or date adjudged permanently and totally disabled:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer at the time of disability determination:
Position with Employer:
Address of Employer:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Immediate Supervisor:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
AFFIDAVIT IN SUPPORT OF APPLICATION FOR TAX CREDIT
DISABLED OR FALLEN LAW ENFORCEMENT OFFICER OR RESCUE WORKER

I, the undersigned, certify that I have read the attached ordinance, that I am entitled to the tax credit for the property described above, and specifically:

1. That the address given is my full-time residence and legal domicile.
2. Please select either Option A or Option B:

Option B: I am the surviving spouse or cohabitant of a deceased law enforcement officer or rescue worker as defined in the ordinance; (ii) I have not married or entered a relationship of cohabitation with another person since the date of the death of the deceased law enforcement officer or rescue worker; and (iii) the deceased law enforcement officer or rescue worker remained permanently and totally disabled as of the date of death and that no administrative agency or a court of competent jurisdiction authorized to make such a determination had determined otherwise.
3. That, if I am the surviving spouse, I was married to the deceased law enforcement officer or rescue worker and domiciled with such person on the date of such person’s death.

4. That, if I am the surviving cohabitant, I was physically living and domiciled with the deceased law enforcement officer or rescue worker on the date of death and continuously for 180 days prior to the date of death.

5. That the disabled or fallen law enforcement officer or rescue worker became disabled or died as a result of injury sustained in the line of duty and the death or disability was not the result of the individual’s willful misconduct or abuse of alcohol or drugs.

6. That, by signing this application, I authorize the Town of Chesapeake Beach to contact the employer of the disabled or fallen law enforcement officer or rescue worker to confirm the facts asserted herein.

I understand that I must notify the Town Administrator’s office if my status changes and that I will no longer be entitled to the tax credit should any of the foregoing circumstances change.

I declare under the penalties of perjury that all information above is true and correct.
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature:
Printed Name:

First NameLast Name
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