ELIGIBLE  NOTI ELIGIBLE  MAP # SS#  FISCAL YEAR  ANNUAL APPLICATION FOR EXEMPTION OF REAL ESTATE TAX ON PERSONAL RESIDENCE OF ELDERLY/PERMANENTLY &  TOTALLY DISABLED PERSONS  Owner's Name Owner's Address_ Legal Description  Date of Birth Telephone  Market Value ofResidence & Land (land not to exceed 1 acre).  TOTAL combined income, during the immediately preceding calendar year, from ALL: sources oft the owners of the dwelling living therein and ofthe owners' relatives, including spouse, living in the dwelling as follows: (total CANNOT! EXCEED $30,000 except the first $7,500 ofincome of each such relative other than the spouse, and first $7,500 ofincome of disabled owner(s), shall not be included in total.) List the yearly amount  received the preceding year in each of the classifications below:  Amount of Social Security $ Including Medicare Amount of Salary $ Amount of] Pension $ Amount of Capital Gains $  Amount of Interest $ Amount ofDividends $ Amount of Other Income $  (Specify)  TOTAL. AMOUNT OF YEARLY INCOME FROM ABOVE: $  RELATIVES INCOME $ LESS EXCLUSIONS: $ GRAND TOTALS  Certification by Social Security Administration, Dept. ofVeteran Affairs, or Railroad Retirement Board: Sworn affidavit by two (2) medical doctors licensed toj practice medicine in the Commonwealth:  YES YES  NO NO  (Attach Copy) (Attach Copy)  Name of Spouse and income from Social Security, etc (ifany)  Names of relatives of owner(s) living in the residence and amount oftheir income over $7,500  Does the total financial worth as ofDecember 31, oft the immediately preceding year oft the owner and spouse, and of owner(s) relatives living therein (excluding the value oft the dwelling and land to be exempted under this  application) exceed $75,000? Livestock $ Vehicles Mortgages $ Other  YES  NO  FILLIN VALUES THAT APPLYTO YOUBELOW:  Furniture and Machinery $ (Cars, Trucks, Trailers, Boats, etc) Mobile Homes Balance on Mortgages  $  $ $  OATH -I, the undersigned applicant, do swear (or affirm) that the foregoing figures and statements are true,  full and correct to the best of my knowledge and belief.  Signature of Applicant Sworn (or affirmed) to before me this  day of  Signature of Commissioner oft the Revenue or Deputy