Form Av-9 - Application For Exclusion Under G.s. 105-277.1

Form Av-9 - Application For Exclusion Under G.s. 105-277.1 - 2008 Page 3

Form AV-9B

WEB DOWLOADED

Rev. 9-07

STATE OF NORTH CAROLINA

YEAR 2008

COUNTY OF _____________________

SUPPLEMENTAL APPLICATION FOR EXCLUSION UNDER G.S. 105-277.1

If your income level is low enough that you are not required to file a Federal Income Tax

Return, please complete the following and attach to the completed Form AV-9.

CLAIMANT

SPOUSE

1. Full Name (as shown on abstract)

_______________ _______________

2. Social Security Number:

_______________ _______________

Social Security Number (SSN) disclosure is mandatory for approval of this application and will be used to establish the identification of the applicant. The SSN

may be used for verification of information provided on this application. The authority to require this number is given by 42 U.S.C. Section 405(c)(2)(C)(i). The

SSN and all income information will be kept confidential. The SSN may also be used to facilitate collection of property taxes if you do not timely and voluntarily

pay the taxes. Using the SSN will allow the tax collector to claim payment of an unpaid property tax bill from any state income tax refund that might

otherwise be owed to you. Your SSN may be shared with the state for this purpose. In addition, your SSN may be used to attach wages or garnish bank

accounts for failure to timely pay taxes.

3. Wages, Salaries, Tips, etc

$___________

$__________

4. Interest

$__________

5. IRA distributions

$__________

6. Pensions and Annuities

$__________