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LOCAL OPTION VETERAN'S PROGRAM

Name(Last) (First) (Middle Initial)

______Grand List

__________________________________________________________________________________________________

Date of Birth(Mo.Day.Yr.) Social Security No.

Spouse's Name(Last)

(First)

(Middle Initial)

Date of Birth(Mo.Day.Yr.) Social Security No.

Mailing Address

City or Town

State

Zip Code

Property Address(Only if different from above)

City or Town of Newtown

State

Zip Code

FILING STATUS:

MARRIED

UNMARRIED

SURVIVING SPOUSE YES NO

(CIRCLE ONE) (CIRCLE ONE)

DID YOU OR WILL YOU FILE A FEDERAL TAX RETURN

INCOME RECEIVED DURING LAST CALENDAR YEAR: A.TAXABLE INCOME- Includes:Federal Adjusted Gross Income or its equivalent. Also includes, but is not limited to wages lottery winnings, taxable pensions, IRA's, interest, dividends and net rental income. A._____________________ B.NON-TAXABLE INTEREST- Example:Interest from Tax Exempt Government Bonds. C.SOCIAL SECURTIY OR RAILROAD RETIREMENT INCOME- (Gross Amount) D.ANY INCOME NOT REFLECTED IN THE ABOVE- Examples:Federal Supplemental Social Security Income, State of Connecticut public assistance payments, General Assistance, Veteran's Pensions, Veterans's disability payments and any other income not listed above. B._____________________ C._____________________

D._____________________

Signature of Applicant or Authorized Agent

Date Signed

TOTAL E._____________________ Phone No. Agent's Relationship

ASSESSORS AFFIDAVIT

____I am satisfied that the above named applicant meets all the necessary statutory ____This claim is disallowed for the following reason:_________________________

AMOUNT OF EXEMPTION GRANTED

$____10,000____(L)

Signature of Assessor or Member of Assessment Staff

Date Signed

Information

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