Contact Information

Last Name *

First Name *

M.I.

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

QUALIFICATIONS FOR TAX EXCEMPTION

To qualify for the senior exemption, you must be a resident that is seventy (70) years of age or older, and
you must reside alone or, if you share your residence with a spouse or a registered domestic partner, at
least one spouse or partner must meet the age criteria for the exemption. The senior exemption does not
apply to households of three or more.

Are you seventy (70) years of age or older or do you share your residence with a spouse or registered
domestic partner who is at least (70) years of age or older.

Are you 70 years or older?

Yes

No

If no, please complete low income or CARES Program exemption application (if applicable).

Name of Spouse or registered domestic partner?

CA Drivers License or Identification Card # of person seeking exemption: (Attach copy)

Name of resident(s) seventy (70) years of age or older: *

UTILITY INFORMATION: Does not apply to water, sewer, and garbage.

Utility 1 *

Account Number 1 *

Name on account 1 *

Utility 2

Account Number 2

Name on Account 2

Utility 3

Account Number 3

Name on Account 3

Utility 4

Account Number 4

Name on Account 4

Utility 5

Account Number 5

Name on Account 5