Application For Homestead Exclusion Under N.c.g.s. 105-277.1 - North Carolina Department Of Revenue - 2004
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1Tax Year 2004
Application for Homestead Exclusion Under N.C.G.S. 105-277.1
Applicant
Spouse
1. Full name as shown on listing card
_________________________
_________________________
2. Residence address
_________________________
_________________________
_________________________
_________________________
3. Is this property your
permanent residence?
_________________________
_________________________
4. Date of birth
_________________________
_________________________
5. Social Security number
_________________________
_________________________
6. Telephone number
_________________________
_________________________
7. If your income level is low enough that you are not required to file a Federal Income Tax Return, enter
your income for the preceding calendar year on this line. $ ________________(If you are required to file a
Federal Return, go to #8 below.)
8. Enter below the required income information from your individual Federal Income Tax Returns for the
preceding calendar year below. If you file a joint return, place all income information under the applicant
column.
Applicant
Spouse
a. Adjusted Gross Income
______________
______________
b. Tax exempt interest
______________
______________
(not included in adjusted gross income)
c. IRA distributions
______________
______________
(not included in adjusted gross income)
d. Pensions and Annuities
______________
______________
(not included in adjusted gross income)
e. Social Security Benefits
______________
______________
(not included in adjusted gross income)
f. Capital gains
______________
______________
(not included in adjusted gross income)
g. Other moneys received
______________
______________
(not included in gross income)
TOTAL
______________
______________
9. You should attach a copy of the first page of your Individual Federal Income Tax Return for 2003 (Form
1040) and/or a copy of your Social Security and/or Disability Income Summary (Form 1099). While your
income tax return is confidential and will be treated as such, you may block out any information except
those items under #8 above.
10. Disabled applicants under 65 years of age as of January 1 must furnish proof of their disability.
Attach a certificate from a licensed physician or from a government agency authorized to determine qual-
ification for disability benefits and place an “X” in the space provided.__________________
AFFIRMATION OF APPLICANT. Under penalties prescribed by law, I hereby affirm that to the best of my
knowledge and belief all information furnished by me in connection with this application is true and complete.
Signature__________________________________ Date___________________ Telephone___________________
ALL INFORMATION IS SUBJECT TO VERIFICATION WITH THE NORTH CAROLINA DEPARTMENT OF REVENUE
Social Security numbers are required to be on this form. We will use these numbers to assist us in the administration of the prop-
erty tax. Our authority to require these numbers is found in 42 USC 405(c)(2)(C)(i), N.C.G.S. 105-296(a), and other applicable laws.
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