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STATE OF NEW MEXICO - 2011 TAX YEAR
APPLICATION-LIMITATION ON
INCREASE IN VALUE FOR SINGLE
Pursuant to 7-36-21.3 NMSA 2000
Application Form
FAMILY DWELLINGS OCCUPIED BY
as Amended in 2008
Revised 2010
LOW INCOME OWNERS 65 YEARS OF
AGE OR OLDER OR DISABLED
INSTRUCTIONS ON REVERSE SIDE
PLEASE READ CAREFULLY
County Name
County Assessor's Phone Number
Tax Year
Applicant's First Name
Middle Initial
Last Name
Present Mailing Address ( Number & Street, P. O. Box or Rural Route )
City & State
Zip Code
Phone Number
Driver's License or Personal ID Certificate ( Number & State )
Date of Birth
Physical Address / Legal Description of Property
Uniform Property Code ( UPC ):
Part 1
Part 1
A. Is the property the applicant's primary residence?
YES
NO
B. Is the property occupied by the applicant and is he or she the current owner?
YES
NO
C. Will the applicant be age 65 or over during the current tax year?
YES
NO
D. Is the applicant disabled?
YES
NO
Part II
Part II
Enter "Modified Gross Income", all income received by the applicant, applicant's spouse and dependants.
Please see section 7-2-2 (L) of the Income Tax Act.
( Round to nearest whole dollar amount.)
Gross Annual Income
1. Compensation;
1
.00
2. Net profit derived from business;
2
.00
3. Gains derived from dealings in property;
3
.00
4. Interest;
4
.00
5. Net rents;
5
.00
6. Royalties
6
.00
7. Dividends;
7
.00
8. Alimony and separate maintenance payments;
8
.00
9. Annuities;
9
.00
10. Income from life insurance and endowment contracts;
10
.00
11. Pensions;
11
.00
12. Discharge of indebtedness;
12
.00
13. Distributive share of partnership;
13
.00
14. Income in respect of a decedent;
14
.00
15. Income from an interest in an estate or trust;
15
.00
16. Social Security benefits;
16
.00
17. Unemployment compensation;
17
.00
18. Workers' compensation benefits;
18
.00
19. Public assistance and welfare benefits;
19
.00
20. Cost-of living allowances; and
20
.00
21. Gifts;
21
.00
.00
Total Modified Gross Income (Add lines 1 thru 21.)
.00
Part III
VALUATION LIMITATION - (To be completed by the County Assessor)
Qualifies
Does not qualify
The records of __________County indicate the property value is $___________as reflected on the __________(Date) Notice of Value.
Valuation Limitation Authorized by:______________________________________ Date:___________________________
Part IV
CERTIFICATION BY PROPERTY OWNER - (To be signed by Applicant)
I certify that I am the legal owner of this property, I am living on this property and the income and age statements made are true and accurate. I understand that false
statements made intentionally on this application may be penalized as provided for in 7-38-92 and 7-38-93 of the Property Tax Code.
Amended income tax returns shall be reported within 30 days of filing.
Applicant Signature:__________________________________________________
Date:_________________________________