Mail completed form with
			supporting documents to:
			SPOKANE COUNTY ASSESSOR
	Form Instructions click here		EXEMPTION SECTION
	Print Page Setup click here		1116 W. Broadway Ave
			Spokane, WA 99260-0010
1- Claimant's Name Spouse or Co-Tenant Name Address If Deceased, Date of Death City, State, Zip Telephone Number --
2- Type of Ownership Owner Contract Purchaser Lease for Life or Life Estate 3- Type of Residence Single Family Residence Mobile Home 4- Parcel Number
5- Include all 2009 income of Claimant, Spouse, Domestic Partner and/or Co-Tenant: (Income Limit $35,000) Please see supporting documents, form instructions click here A- Social Security (Less Medicare) K- Adult Assisted Living Expenses B- Disability Income L- Nursing Home Expenses C- Pensions or Retirement Income M- In-Home Care Expenses D- IRA OR Annuity Income Received, Taxable & NON-Taxable Interest & Dividends N- Non-Reimbursed Prescriptions E- Railroad Retirement (Both Tiers) O- Other Adjustments to AGI F- Militry Retirement/VA Benefits. Do not include service connected disaablility pay Sub-Total of Expenses (Add Columns K-O) G- Business & Rental Income before Depreciation H- Wages Total Income for 2009 I- Total Capital Gains (DO NOT deduct losses) Note: if GREATER than $35,000, you are NOT eligible for exemption J- All other income (including grants, gambling winnings, public assistance, unemployment, alimony, etc) Sub-Total of Income (Add Columns A-J)
ATTACH ALL 2009 INCOME DOCUMENTS (INCLUDE TAX RETURN)
It is your responsibility to notify the Assessor's Office if your household income changes during the next four years
6- I am/We are applying for an exemption on the described property and certify the following:
I currently occupy this property as my principal residence as of December 31, 2009
I am or will be 62 years of age or older on or before December 31, 2010
I have a disability resulting in the inability to pursue regular gainful employment.Proof Required. Click to view form instruction
I am a surviving spouse of a person who was approved for this exemption and I am at least 57 years of age.
Birth date	Spouse Birth date	Year Property Purchased	Year Property Occupied
Any exemption granted through willfully providing erroneous information shall be subject to the correct tax being assessed for the last three years plus a 100% penalty (RCW 84.36.387)
I swear under the penalties of perjury that all foregoing statements are true. (Click to view form instruction)
Signature of Claimant	Date	Witness	Date
Deputy	Date	Witness	Date
This Claim is SUBJECT TO AUDIT by the Department of Revenue
Application# FOR COUNTY USE ONLY Denied     2009 Type   Frozen Year   ATC #     2010 Type   Frozen $   Yr Eligible   Comments