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2. 
4. SECTION 1: General Questions
6. Is this an original application or a renewal? *

   1. Original
   2. Renewal
8. Has the applicant applied for an exemption previously and was denied? *

   1. Yes
   2. No
10. Was the service of the veteran during a War or Armed Conflict in which the United State was engaged? *

    1. Yes
    2. No
12. As a result of military service, is the veteran rated at 100% disabled, permanent and total as stated on a VA award letter?*

    1. Yes
    2. No
14. As a result of military service, is the veteran rated at less than 100% disabled, but listed as permanent and total AND unemployable? *

    1. Yes
    2. No
16. As a result of military service, is the veteran blind, paraplegic, of has sustained a loss of limb? *

    1. Yes
    2. No
18. Is the total gross income of the veteran less than $108,046 including all sources such as VA disability compensation? *

    1. Yes
    2. No
20. Is the applicant exempt from filing income taxes (Form 1040)? *

    1. Yes
    2. No
22. In whose name is the title for the property?*
    -- Select One --Solely in the veteran’s nameJointly in the veteran and spouse’s nameA trust, another person’s name, the veteran and another person’s name
24. Is the property occupied as the principal dwelling by person seeking the exemption?*

    1. Yes
    2. No
26. Does any portion of the property generate income?*

    1. Yes
    2. No
28. If yes, please describe:
30. Does the applicant own any real estate they do not occupy?*

    1. Yes
    2. No
32. If yes, Address or Non-Rental Property:
34. or Address of Rental Property:
36. SECTION 2: Applicant Information
38. First Name*
39. Last Name*
41. Date of Birth*
42. Phone Number*
43. Email*
45. Address*
47. City*
48. State*
49. Zip*
51. County*
52. Marital Status*
    -- Select One --MarriedSingleWidowedDivorcedSeparatedDomestic Partnership
54. Spouse's Information
56. First Name
57. Last Name
59. Date of Birth
60. Email
62. Address
64. City
65. State
66. Zip
68. County
70. SECTION 3: Other Dependents (residing in the household, except spouse of listed above)
72. First Name
73. Last Name
75. Date of Birth
76. Relationship
    -- Select One --Son/DaughterGrandson/GranddaughterNiece/NephewBrother/Sister
78. First Name
79. Last Name
81. Date of Birth
82. Relationship
    -- Select One --Son/DaughterGrandson/GranddaughterNiece/NephewBrother/Sister
84. First Name
85. Last Name
87. Date of Birth
88. Relationship
    -- Select One --Son/DaughterGrandson/GranddaughterNIece/NephewBrother/Sister
90. SECTION 4: Veteran Military Information
92. Branch of Service*
    -- Select One --Air ForceAir National GuardArmyArmy National GuardCoast GuardMarinesNavy
93. Status*
    -- Select One --ActiveReserveGuard
95. Date of Entry*
96. Date of Discharge*
97. Discharge Under Honorable Conditions?*

    1. Yes
    2. No
99. Do you have a physical disability?*

    1. Yes
    2. No
100. If yes, is a service-connected disability?

     1. Yes
     2. No
102. SECTION 5: Employment Status
104. Currently Employed?*

     1. Yes
     2. No
     3. Retired
106. Employer (Company) Name
108. Employer Address
110. Employer Phone Number
111. Start Date with Employer
112. Date of Last Pay
114. Spouse/Domestic Partner Employment History
116. Currently Employed?

     1. Yes
     2. No
117. Employer (Company) Name
119. Employer Address
121. Employer Phone Number
122. Start Date with Employer
123. Date of Last Pay
125. SECTION 6: Documents
127. The Office of Veterans Affairs will follow-up with you upon receipt of your application is received. Please be prepared to produce the following documents. Required documents*
129. VA Award Letter*
130. W-2
132. SSA Form 1099*
133. 1040 Tax Return or 1099-R
135. DD-214, DD-256 (Reserves), or NGB-22 (National Guard)*
136. Lease Agreement (if you receive income from a rental property)
138. Property Title*
139. 1099-DIV, 1099-MISC, 1099-C or W2G (if you receive interest, dividends, or capital gains from investments)
141. VA Award Letter stating 100% disability Permanent and Total or Unemployable*
142. Blind or Paralyzed Veteran State Pension Letter
144. Marriage License (if applicable)
145. Veteran Death Certificate (if applicant is a Surviving Spouse)
147. CERTIFICATION
149. By signing this application, the applicant certifies that the information provided is true and correct to the best of his knowledge, information and belief. The law provides severe penalties including fines and imprisonment for making false statements on official forms such as this Application for Exemption from Real Property Taxes. I understand that this verification is made subject to the penalties of 18 Pa C.S.A. § 4904 pertaining to unsworn falsification to authorities.
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