DISABLED HERO TAX CREDIT APPLICATION

DISABLED HERO TAX CREDIT APPLICATION
Name of Disabled Hero
Daytime Phone No.
Address of Property
Mailing Address
Email
example@example.com
(If different than address of property)
Is this a residential owner-occupied property?
No (If no, this property is not eligible for tax credit)
Date Adjudged to be permanently & totally disabled

MonthDayYear
Date
File Upload

(Please provide copy of disability documents from qualifying agency)
Cancelof
Information to be provided by law enforcement or rescue worker service:
Name of Employer
Name of Authorized Representative
Title of Authorized Representative
Telephone No.
Position Held by Disabled Hero
Ruled Disabled- Please Check One

as a result of or in the course of employment as a law enforcement officer or correctional Officer; while a resident of Carroll County and in active service of Carroll County or a jurisdiction with reciprocity.while in the active service of a career or volunteer fire, rescue, or emergency medical service of Carroll County or a jurisdiction with reciprocity.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE PREPARED AND EXAMINED THIS APPLICATION, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS TRUE, CORRECT, AND COMPLETE
SIGNATURE OF APPLICANT

Clear
Date

MonthDayYear
Date
SIGNATURE OF AUTHORIZED REPRESENTATIVE

Clear
Date

MonthDayYear
Date
Should be Empty: