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Form PTR-1A
Homeowners
Verification of 2019 and 2020 Property Taxes
(Use blue or black ink. See instructions for completion on back.)
Part I — To Be Completed by Applicant (Part II to be completed by tax collector)
Social Security # – – Spouse’s/CU Partner’s Social Security # – –
Name
Last Name, First Name, and Middle Initial (Follow with first name and initial of spouse/CU partner if filing jointly. Only enter spouse/CU partner’s last name if different.)
Address
Street City State ZIP Code
Block Lot Qualifier
2019 2020
A. Did you own this property with someone who was not your spouse/CU partner? Yes No Yes No
% %
B. If yes, indicate the share (percentage) of property that you (and your spouse/CU partner) owned.
C. Did this property consist of multiple units? Yes No Yes No
% %
D. If yes, indicate the share (percentage) of property used as your main home.

Part II — To Be Completed by Tax Collector

2019 Property Taxes 2020 Property Taxes
Check box if property had a tax appeal for 2019 ................... Check box if property had a tax appeal for 2020 ...................
Check box if property had an added assessment for 2019 ... Check box if property had an added assessment for 2020 ...

1. Assessed Value ...............................................$ __________ 1. Assessed Value ...............................................$ __________

2. Tax Rate (including fire and other 2. Tax Rate (including fire and other
special tax rates) ............................................... __________ % special tax rates) ............................................... __________ %

3. Total Property Taxes 3. Total Property Taxes
(Multiply line 1 by line 2).................................. $ __________ (Multiply line 1 by line 2).................................. $ __________

4. REAP Credit (if any) .................. $ _________ 4. REAP Credit (if any) .................. $ _________

5. Enter amount from line 3. If applicant 5. Enter amount from line 3. If applicant
answered “Yes” to Questions A and/or C answered “Yes” to Questions A and/or C
above, you must apportion the amount on above, you must apportion the amount on
line 3 when completing this line. line 3 when completing this line.
(See instructions on back.).............................. $ _________ (See instructions on back.).............................. $ _________

Homeowners, enter this amount Homeowners, enter this amount
on line 14 of your Form PTR-1 on line 13 of your Form PTR-1

Under the penalties of perjury, I certify that I am the local tax collector of ,
where the above property is located. I further certify that the above-stated amounts of property taxes due were paid for Calendar Years
2019 and 2020 and are true and accurate to the best of my knowledge. I have placed my stamp below for verification.

(Name) (Date)

(Title)

(If you complete this form, be sure to enclose it with your Form PTR-1 application.)

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Form PTR-1A – Instructions

Part I – To Be Completed by Applicant units was your main home. You occupied one-fourth
(25%) of the property as your main home. Enter 25% as
Social Security Number. If your marital/civil union status
your share of occupancy.
as of De cember 31, 2020, was single, enter only your Social
Security number in the space provided on Form PTR-1A. If
your status as of December 31, 2020, was married/CU cou- Part II – To Be Completed by Tax Collector
ple, you must report both applicants’ numbers in the order
Enter the appropriate amounts for Calendar Years 2019 and
in which the names are listed on the application. If you were
2020 as follows:
married or in a civil union but living apart from your spouse/
CU partner, and you did not have access to or receive sup- Line 1. Enter the assessed value of the property for each
port from their income, you are considered “Single” for pur- calendar year. If the assessed value changed for the tax
poses of the Property Tax Reimbursement. You should enter year, use the final assessed value.
only your Social Security number on Form PTR-1A.
Line 2. Enter the tax rate for each calendar year. Include
Name and Address. Print or type your name (last name fire and other special tax rates.
first) and complete address of the property for which you are
claiming the reimbursement in the spaces provided. Also in- Line 3. Multiply the assessed value on line 1 by the tax
clude your spouse’s/CU partner’s name if filing jointly. rate on line 2 and enter the result on line 3. This is the
total amount of taxes due for each calendar year before
Block/Lot/Qualifier. Enter the block and lot numbers of the any deductions and/or credits are subtracted (e.g., senior
principal residence (main home) for which you are claiming citizen’s deduction, Homestead Benefit credit).
the reimbursement in the spaces provided. Include qualifier
if applicable. (Only condominiums may have qualifiers as- Line 4. Enter the amount of any Regional Efficiency Aid
signed to them.) Program (REAP) credit the homeowner(s) received for each
calendar year.
A. Multiple Owners. Check “Yes” if you owned the
property that was your main home with someone who
Line 5. If the applicant answered “No” to the questions at
was not your spouse/CU partner — even if the other
both line A and line C, enter the amount of property taxes
owner(s) did not live there. For example, you and your
from line 3.
sister owned the home you lived in. If you (and your
spouse/CU partner) were the sole owner(s), check “No.”
If the applicant answered “Yes” at either line A or line C, you
B. Percentage of Ownership. If you answered “Yes” at must apportion the amount of property taxes to be entered
line A, enter the share (percentage) of the property on line 5. If title to the property is held by the eligible
that you (and your spouse/CU partner) owned. For ex- applicant with others as tenants in common or joint tenants
ample, you and your spouse owned a home with your (except in the case of husband and wife or CU partners),
sister. Your sister did not live with you, and you and or if the property consists of more than one unit, the
your spouse paid all the property taxes. You must enter applicant is only eligible for the proportionate share of the
50% as your share of ownership because you and your reimbursement that reflects the percentage of ownership or
spouse owned only one-half (50%) of the property. The the percentage of occupancy.
shares of ownership of the property are considered to
be held equally by all owners. If the shares of ownership Multiple Owners. If the applicant answered “Yes” at
are not equal, you must provide documentation as to the Part I, line A, multiply the amount of property taxes on
percentage of ownership. line 3 by the percentage of ownership shown at Part I,
line B, and enter the result on line 5.
C. Multi-Unit Properties. Check “Yes” if your main home
was a unit in a multi-unit property that you owned. For Multi-Unit Properties. If the applicant answered “Yes”
example, you owned a property consisting of four resi- at Part I, line C, multiply the amount of property taxes on
dential units and you occupied one of the units as your line 3 by the percentage of occupancy shown at Part I,
main home. If the property is not a multi-unit property, line D, and enter the result on line 5.
check “No.”
If the applicant answered “Yes” to the questions at both
Note: Residents of condominium complexes, co-ops, lines A and C in the same year, multiply the amount of
and continuing care retirement facilities are not con- property taxes on line 3 by the percentage of occupancy
sidered to be living in multi-unit properties and should shown at Part I, line D, and enter the result on line 5.
check “No.”
Certification. Complete the certification portion of Form
D. Percentage of Occupancy. If you answered “Yes” at PTR-1A. Sign and date the certification and place the au-
line C, enter the share (percentage) of the property used thorization stamp in the space provided. (Use blue or black
as your main home. For example, you owned a four- ink.)
unit property. The units are equal in size, and one of the

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