Elderly/Totally Disabled Application

1. NAME (Last)
(First) 
(Middle Initial) 
YOUR BIRTH DATE 
YOUR SOCIAL SECURITY NO. 
2. SPOUSE'S NAME (Last)
(First) 
(Middle Initial) 
SPOUSE'S BIRTH DATE  
SPOUSE'S SOCIAL SECURITY NO. 
CIVIL UNION 
MARRIED 
UNMARRIED 
SURVIVING SPOUSE (AGE 50 TO 65) PROOF REQUIRED 
YES (Attach Copy) 
 NO 
A.$ 
B.$ 
 
E. TOTAL Add lines 7A through 7D
this applicant
ASMNT:$  
   APPLICANT'S GROSS ASMT: $ - 
Subtract Exemptions for:      Blind - 
$ 
Veteran's - 
$  
Local Options - 
Add'l Vets - 
$ 
$  
 
ASSESSOR'S
 This claim is disallowed for the following reason:  
M-35H Rev. 1/2024
STATE OF CONNECTICUT - OFFICE OF POLICY AND MANAGEMENT 
APPLICATION FOR TAX CREDITS 
ELDERLY AND TOTALLY DISABLED HOMEOWNER 
FILING PERIOD: FEBRUARY lst through MAY 15th 
OWNER 
GRAND LIST 
3. MAILING ADDRESS
 CITY/TOWN 
     STATE     
     ZIP 
4. PROPERTY ADDRESS (if different than above)  CITY/TOWN
 STATE    
 ZIP 
    OTHER NAME ON PROPERTY 
5. FILING STATUS:
CHECK ONLY ONE:
IF SPOUSE IS A RESIDENT OF A HEALTH CARE 
OR A NURSING HOME FACILITY IN CT AND 
ON TITLE XIX         CURRENT PROOF REQUIRED 
IFAPPLICANT IS TOTALLY  
DISABLED 
CHECK HERE: 
CURRENT  PROOF REOUIRED 
CHECK HERE: 
6. DID OR WILL YOU FILE A FEDERAL TAX RETURN FOR THE GRAND LIST YEAR?
7. CT QUALIFYING INCOME RECEIVED DURING LAST CALENDAR YEAR:
A. GROSS INCOME - Includes: Federal Gross Income or its equivalent. Such as, but not limited
to wages, lottery winnings, pensions, IRA withdrawals, interest, dividends, and net rental income (excluding depreciation).
B. NON-TAXABLE INTEREST - Example: Interest from Tax Exempt Government Bonds
C. SOCIAL SECURITY OR RAILROAD RETIREMENT INCOME - Add Medicare premiums (Attach SSA 1099)
C.$
D. ANY OTHER INCOME NOT REFLECTED IN THE ABOVE - Examples: Federal Supplemental Security Income,
State of Connecticut public assistance payments, Veteran's Disability Pensions, and any other income not listed above.
D.$ 
E. $
8. APPLICANT'S/
AUTHORIZED
AGENT'S
AFFIDAVIT
The applicant or authorized agent deposes that the above statements are true and complete and claims tax relief under provisions 
of the Connecticut General Statutes. The property for which tax relief is claimed, is the permanent residence/domicile of the    
applicant. He/she is not receiving State Elderly tax benefits under section 12-129b or section 12-170d, in any town. The penalty for 
making a false affidavit is the refund of all credits improperly taken and a fine of not more than $500.00. Your signature signifies that 
this affidavit has been read and understood. 
SIGNATURE OF APPLICANT OR AUTHORIZED AGENT 
DATE 
APPLICANT'S or AGENT'S PHONE NO. 
AGENT'S RELATIONSHIP 
X 
STOP! DO NOT WRITE BELOW THIS LINE - FOR ASSESSOR'S USE ONLY 
9. Date Application Received:
10. Total percentage of property
/ 
/ 
(in fee or in life use) owned by 
14.Allowable Table Percentage:
% 
% 
PROPERTY'S GROSS 
15. Credit Maximum: 
* 
a. Line 13 or **13a X Line 14
$ 
b.Table Ceiling   X Line 10
Disabled - 
* Based on % of 
16. a.Lesser of Line 15a or 15b
ownership 
b. Minimum Grant
11. Net Assessment (based on APPLICANT'S GROSS ASMT.
minus total exemptions) (MUST agree with the continuation sheet)
17. CREDIT AMOUNT
   Greater of 16a or 16b 
$ 
12. 
13. Amount of Property Tax:   or  **13a. Amount of Frozen Tax:  **NOTE: If local option freeze program is offered by municipality
$ 
$    
     you must enter frozen tax amount in Box 13a and Box 15a 
 Mill Rate: 
I am satisfied that the above named applicant meets all the necessary statutory requirements 
AFFIDAVIT 
{Per Connecticut General Statutes Section 12-170cc an applicant has the right to appeal the Assessor’s decision to the Secretary of 
OPM, in writing, within 30 business days from the date of notice given by the Assessor} 
SIGNATURE OF ASSESSOR OR MEMBER OF ASSESSOR'S STAFF 
Date 
DISTRIBUTION:  Original - Assessor 
Copy - Applicant 
Copy - Tax Collector 
Electronic submission to OPM 
_______________
___________
0.00