SURVIVING SPOUSE OF A FALLEN HERO TAX CREDIT APPLICATION
Property Account No:
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Name of Fallen Hero
Date of Death (Please provide copy of death certificate)
/
Month
/
Day
Year
Date
Name of Surviving Spouse
Daytime Phone No.
Address of Property
Mailing Address
(If different than address of property)
Have you remarried or cohabitated since the Fallen Hero’s date of death?
Yes (If yes, then not eligible for tax credit)
No
Do you have children with the Fallen Hero?
Yes (If yes, please list name(s) and date of birth below)
No
Name of Child
DOB
Name of Child
DOB
Is this a residential owner-occupied property?
Yes
No (If no, this property is not eligible for tax credit)
Information to be provided by law enforcement or rescue worker service:
Name of Employer
Name of Supervisor
Title
Telephone No.
Position Held by Fallen Hero
Ruled Death- Please check one
1) 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.
2) while in the active service of a 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
Date
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Month
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Day
Year
Date
Signature of Applicant
Signature of Supervisor
Date
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Month
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Day
Year
Date
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