Elderly-Totally Disabled Homeowner Application (PDF)

1. NAME (Last) 
(First) 
(Middle Initial) 
      
      
      
YOUR BIRTH DATE (mm/dd/yyyy) 
  
YOUR SOCIAL SECURITY NO. 
  
2. SPOUSE'S NAME (Last) 
(First) 
(Middle Initial) 
      
      
      
SPOUSE'S BIRTH DATE (mm/dd/yyyy) 
  
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 -       
$       
LocalOptions -       
Add'l Vets -       
$       
      
      
$       
 
      
  
ASSESSOR'S
- This claim is disallowed for the following reason:       
 
      
   
   
   
 
      
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PLEASE PRINT OR TYPE 
M-35H Rev. 12/2018 
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 (No. and Street) 
CITY OR TOWN (Don't Abbreviate) 
STATE 
ZIP CODE 
4. PROPERTY ADDRESS (No. and Street) 
ONLY IF DIFFERENT FROM 3. ABOVE 
CITY OR TOWN 
STATE 
ZIP CODE 
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.$ 
EXPLAIN OTHER: 
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 signed (mm/dd/yyyy) 
APPLICANT'S or AGENT'S PHONE NO. 
AGENT'S RELATIONSHIP 
X 
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(           ) 
STOP! DO NOT WRITE BELOW THIS LINE - FOR ASSESSOR'S USE ONLY 
9. Date Application Received: 
10. Total percentage of property 
/ 
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(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.TableCeiling   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 signed (mm/dd/yyyy) 
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DISTRIBUTION:  Original - Assessor 
Copy - Applicant 
Copy - Tax Collector 
Electronic submission to OPM