Contact Information

Last Name *

First Name *

M.I.

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

OTHER RESIDENTS LIVING IN THE HOME

Name 1: *

Age 1: *

Relationship 1: *

Income 1: *

Name 2:

Age 2:

Relationship 2:

Income 2:

Name 3:

Age 3:

Relationship 3:

Income 3:

Name 4:

Age 4:

Relationship 4:

Income 4:

Name 5:

Age 5:

Relationship 5:

Income 5:

Name 6:

Age 6

Relationship 6:

Income 6:

QUALIFICATIONS FOR TAX EXEMPTION

Total household income not to exceed the Total Combined Annual Income listed below.
Household size Total Combined Annual Income Limit

1$45,700/year

2$52,200/year

3$58,750/year

4$65,250/year

5$70,500/year

6$70,700/year

7$80,950/year

8$86,150/year