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Real Estate Tax Exemption Pre-Screening Form

  1. HHS Logo
  2. SECTION 1: General Questions
  3. Is this an original application or a renewal? *
  4. Has the applicant applied for an exemption previously and was denied? *
  5. Was the service of the veteran during a War or Armed Conflict in which the United State was engaged? *
  6. As a result of military service, is the veteran rated at 100% disabled, permanent and total as stated on a VA award letter?*
  7. As a result of military service, is the veteran rated at less than 100% disabled, but listed as permanent and total AND unemployable? *
  8. As a result of military service, is the veteran blind, paraplegic, of has sustained a loss of limb? *
  9. Is the total gross income of the veteran less than $108,046 including all sources such as VA disability compensation? *
  10. Is the applicant exempt from filing income taxes (Form 1040)? *
  11. Is the property occupied as the principal dwelling by person seeking the exemption?*
  12. Does any portion of the property generate income?*
  13. Does the applicant own any real estate they do not occupy?*
  14. SECTION 2: Applicant Information
  15. Spouse's Information
  16. SECTION 3: Other Dependents (residing in the household, except spouse of listed above)
  17. SECTION 4: Veteran Military Information
  18. Discharge Under Honorable Conditions?*
  19. Do you have a physical disability?*
  20. If yes, is a service-connected disability?
  21. SECTION 5: Employment Status
  22. Currently Employed?*
  23. Spouse/Domestic Partner Employment History
  24. Currently Employed?
  25. SECTION 6: Documents
  26. 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*
  27. VA Award Letter*
  28. W-2
  29. SSA Form 1099*
  30. 1040 Tax Return or 1099-R
  31. DD-214, DD-256 (Reserves), or NGB-22 (National Guard)*
  32. Lease Agreement (if you receive income from a rental property)
  33. Property Title*
  34. 1099-DIV, 1099-MISC, 1099-C or W2G (if you receive interest, dividends, or capital gains from investments)
  35. VA Award Letter stating 100% disability Permanent and Total or Unemployable*
  36. Blind or Paralyzed Veteran State Pension Letter
  37. Marriage License (if applicable)
  38. Veteran Death Certificate (if applicant is a Surviving Spouse)
  40. 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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  42. This field is not part of the form submission.