Third Party Notification For Real Property Taxes Application Form printable pdf download

Third Party Notification For Real Property Taxes Application Form

Third Party Notification for Real Property Taxes Application

REQUEST FOR MAILING OF DUPLICATE TAX BILLS

OR STATEMENTS OF UNPAID TAXES TO A THIRD PARTY

I request that a duplicate of any tax bill or statement of unpaid taxes with respect to my property as described

below be mailed to the person whom I have designated.

In making this request, I understand that neither the tax collecting officer nor any other local government

employee has any liability if for any reason the duplicate is not mailed to or not received by my designee.

SECTION 1 - TAXPAYER INFORMATION

The Applicant is (check one):

Taxpayer Name ______________________________________________

At least 65 years of age

Disabled

Mailing Address ______________________________________________

SECTION 2 - THIRD PARTY DESIGNEE

City & State ___________________________ Zip Code _____________

Third Party Name ____________________________________________

Property Identification (as shown on assessment roll) _____________

Mailing Address _____________________________________________

____________________________________________________________

City & State __________________________ Zip Code ____________

Tax Billing Address (if different than mailing address) _____________

Telephone __________________________________________________

____________________________________________________________

___________________________________

____________________

___________________________________

_____________________

Signature

Date

Signature

Date

SECTION 3 - PHYSICIAN’S CERTIFICATION OF PHYSICAL OR MENTAL DISABILITY

Taxpayer Name: _____________________________________________________________________________________________________________

Office Address: _____________________________________________________________________________________________________________

NYS License Number ____________________________________________________

Date of Issue ___________________________________

Patient’s Name ______________________________________________________________________________________________________________

Patient’s Address ____________________________________________________________________________________________________________

Does patient have a physical or mental impairment which substantially limits one or more

major life activities (e.g., walking)? ...........................................................................................

YES

I certify that all statements made in this section are true and correct to the best of my knowledge and professional belief.

______________________________________________________________

____________________________________

Signature of Physician

Date

Third Party Notification For Real Property Taxes Application Form

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