PDF document

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Form PTR-1A
Homeowners
Verification of 2018 and 2019 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 Initial (Joint filers enter first name and initial of each - Enter spouse’s/CU partner’s last name ONLY if different)
Address
Street City State ZIP Code
Block Lot Qualifier
2018 2019
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 principal residence.

Part II — To Be Completed by Tax Collector

2018 Property Taxes 2019 Property Taxes
Check box if property had a tax appeal for 2018 ................... Check box if property had a tax appeal for 2019 ...................
Check box if property had an added assessment for 2018 ... Check box if property had an added assessment for 2019 ...

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
2018 and 2019 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 one-fourth (25%) of the property as your principal resi-
dence. Enter 25% as your share of occupancy.
Social Security Number. If your marital/civil union status
as of De cember 31, 2019, was single, enter only your Social
Security number in the space provided on Form PTR-1A. If Part II – To Be Completed by Tax Collector
your status as of December 31, 2019, was married/CU cou-
Enter the appropriate amounts for Calendar Years 2018 and
ple, you must report both applicants’ numbers in the order
2019 as follows:
in which the names are listed on the application. If you were
married or in a civil union but living apart from your spouse/ Line 1. Enter the assessed value of the property for each
CU partner, and you did not have access to or receive sup- calendar year. If the assessed value changed for the tax
port from their income, you are considered “Single” for pur- year, use the final assessed value.
poses of the Property Tax Reimbursement. You should enter
only your Social Security number on Form PTR-1A. Line 2. Enter the tax rate for each calendar year. Include
fire and other special tax rates.
Name and Address. Print or type your name (last name
first) and complete address of the property for which you are Line 3. Multiply the assessed value on line 1 by the tax
claiming the reimbursement in the spaces provided. Also in- rate on line 2 and enter the result on line 3. This is the
clude your spouse’s/CU partner’s name if filing jointly. total amount of taxes due for each calendar year before
any deductions and/or credits are subtracted (e.g., senior
Block/Lot/Qualifier. Enter the block and lot numbers of the citizen’s deduction, Homestead Benefit credit).
principal residence for which you are claiming the reimburse-
ment in the spaces provided. Include qualifier if applicable. Line 4. Enter the amount of any Regional Efficiency Aid
(Only condominiums may have qualifiers assigned 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 principal residence with someone
Line 5. If the applicant answered “No” to the questions at
who was not your spouse/CU partner — even if the
both line A and line C, enter the amount of property taxes
other owner(s) did not live there. For example, you and
from line 3.
your 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 principal
residence was a unit in a multi-unit property that you Multi-Unit Properties. If the applicant answered “Yes”
owned. For example, you owned a property consisting at Part I, line C, multiply the amount of property taxes on
of four residential units and you occupied one of the line 3 by the percentage of occupancy shown at Part I,
units as your principal residence. If the property is not a line D, and enter the result on line 5.
multi-unit property, 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 principal residence. For example, you owned a ink.)
four-unit property. The units are equal in size, and one
of the units was your principal residence. You occupied

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