DISABLED HERO TAX CREDIT APPLICATION

DISABLED HERO TAX CREDIT APPLICATION
Name of Disabled Hero
Daytime Phone No.
Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit yearDate
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
Format: (000) 000-0000.
Telephone No.
Position Held by Disabled Hero
Ruled Disabled- Please Check One
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SIGNATURE OF AUTHORIZED REPRESENTATIVE
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: