Form PTR-2A
 Homeowners
                   Verificationof2019PropertyTaxes
                   (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 
        LastName,FirstName,andInitial(Jointfilersenterfirstnameandinitialofeach-Enterspouse’s/CU partner’s last name ONLY if different) 

Address 
        Street                                   City                                                              ZIPCode

Block               Lot                                                        Qualifier
A.  Did you own this property with someone who was not your spouse/CU partner?                                                                Yes   No 
B.  If yes, indicate the share (percentage) of the property that you (and your spouse/CU partner) owned.                                             %
C.  Did this property consist of multiple units?                                                                                              Yes   No 
D.  If yes, indicate the share (percentage) of the property used as your principal residence.                                                        %

Part II — To Be Completed by Tax Collector

                   2019 Property Taxes 

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

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

TaxRate(includingfireandotherspecialtaxrates) ....................................................................                                   %

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

REAP  Credit(ifany)  ...................................................................................$ 

Enteramountfromline3.Ifapplicantanswered“Yes”toQuestions Aand/orC  
 above, you must apportion the amount on line 3 when completing this line.  
  (See instructions on back.)  ...................................................................................................... $ 

        Homeowners, enter this amount on line 10 of your Form PTR-2

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 Year 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-2 application.)

                              Form PTR-2A – Instructions

Part I – To Be Completed by Applicant                          four-unit property. The units are equal in size, and one 
Social Security Number. If your marital/civil union status     of the units was your principal residence. You occupied 
as of De cember 31, 2019, was single, enter only your Social   one-fourth (25%) of the property as your principal resi-
Security number in the space provided on Form PTR-2A. If       dence.Enter25%       as your share of occupancy.
your status as of December 31, 2019, was married/CU cou-
ple, you must report both applicants’ numbers in the order     Part II – To Be Completed by Tax Collector
in which the names are listed on the application. If you were  EntertheappropriateamountsforCalendar   Year2019as
married or in a civil union but living apart from your spouse/ follows:
CU partner, and you did not have access to or receive sup-
portfromtheirincome,youareconsidered“Single”forpur         -   Line 1.Entertheassessedvalueoftheproperty.Ifthe
poses of the Property Tax Reimbursement. You should enter      assessedvaluechangedforthetaxyear,usethefinal
only your Social Security number on Form PTR-2A.               assessed value.

Name and Address. Print or type your name (last name           Line 2. Enterthetaxrate.Includefireandotherspecialtax
first)andcompleteaddressofthepropertyforwhichyouare            rates.
claiming the reimbursement in the spaces provided. Also 
includeyourspouse’s/CUpartner’snameiffilingjointly.            Line 3. Multiply the assessed value on line 1 by the tax 
                                                               rate on line 2 and enter the result on line 3. This is the total 
Block/Lot/Qualifier.Entertheblockandlotnumbersof               amount of taxes due before any deductions and/or credits 
the principal residence for which you are claiming the         are subtracted (e.g., senior citizen’s deduction, Homestead 
reimbursementinthespacesprovided.Includequalifier              Benefitcredit).
ifapplicable.(Onlycondominiumsmayhavequalifiers
assigned to them.)                                             Line 4.EntertheamountofanyRegionalEfficiency           Aid
                                                               Program(REAP)creditthehomeowner(s)received.
A.  Multiple Owners.Check“Yes”ifyouownedthe
property that was your principal residence with someone        Line 5.Iftheapplicantanswered“No”tothequestionsat
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          Iftheapplicantanswered“Yes”ateitherline AorlineC,you
“No.”                                                          must apportion the amount of property taxes to be entered 
                                                               on line 5. If title to the property is held by the eligible 
B.  Percentage of Ownership.Ifyouanswered“Yes”at               applicant with others as tenants in common or joint tenants 
line A, enter the share (percentage) of the property that      (except in the case of husband and wife or CU partners), 
you (and your spouse/CU partner) owned. For exam-              or if the property consists of more than one unit, the 
ple, you and your spouse owned a home with your                applicant is only eligible for the proportionate share of the 
sister. Your sister did not live with you, and you and         reimbursementthatreflectsthepercentageofownershipor
your spouse paid all the property taxes. You must enter        the percentage of occupancy.
50% as your share of ownership because you and your 
spouse owned only one-half (50%) of the property. The          Multiple Owners.Iftheapplicantanswered“Yes”at
shares of ownership of the property are considered to be       Part I, line A, multiply the amount of property taxes on 
held equally by all owners. If the shares of ownership are     line 3 by the percentage of ownership shown at Part I, 
not equal, you must provide documentation as to the per-       line B, and enter the result on line 5. 
centage of ownership.
                                                               Multi-Unit Properties. If the applicant answered 
C.  Multi-Unit Properties. Check“Yes”ifyourprincipal           “Yes”atPartI,lineC,multiplytheamountofproperty
residence was a unit in a multi-unit property that you         taxes on line 3 by the percentage of occupancy 
owned. For example, you owned a property consisting            shown at Part I, line D, and enter the result on line 5. 
of four residential units and you occupied one of the 
units as your principal residence. If the property is not a    Iftheapplicantanswered“Yes”tothequestionsatboth
multi-unitproperty,check“No.”                                  lines A and C, multiply the amount of property taxes on line 
                                                               3 by the percentage of occupancy shown at Part I, line D, 
  Note: Residents of condominium complexes, co-                and enter the result on line 5.
ops, and continuing care retirement facilities are not 
considered to be living in multi-unit properties and           Certification.CompletethecertificationportionofForm
shouldcheck“No.”                                               PTR-2A.Signanddatethecertificationandplacethe
                                                               authorization stamp in the space provided. (Use blue or 
D.  Percentage of Occupancy. Ifyouanswered“Yes”at              black ink.)
line C, enter the share (percentage) of the property used 
as your principal residence. For example, you owned a