APPLICATION FOR TAX EXEMPTION FOR AMBULANCE-TYPE …
APPLICATION FOR TAX EXEMPTION FOR SPECIALLY EQUIPED MOTOR VEHICLES FOR DISABLED VETERANS
CGS 12-81h 2019 GRAND LIST
LAST NAME FIRST NAME
ADDRESS
1. Description of vehicle for which exemption is requested.
MAKE MODEL YEAR REG.NO. V.I.N.
_______________________________________________________________________________
2. Is this vehicle used exclusively for or by the disabled veteran applying for exemption?
Yes No
4. Describe any modifications or special equipment (i.e. lifts, hand controls, etc.) which
were required to accommodate the incapacitated persons.
_______________________________________________________________________________
_______________________________________________________________________________
5. Estimate the cost of these modifications. $_______________
6. APPLICANT’S AFFIDAVIT
The applicant herein claims a tax exemption under provisions of the State General Statutes and the
Town ordinance and certifies that the above statements are true and complete.
SIGNATURE OF APPLICANT:
DATE SIGNED: TELEPHONE NUMBER:
ASSESSOR’S AFFIDAVIT
Approved ________ Exemption Amount Approved _______________
Not Approved _______
SIGNATURE OF ASSESSOR
OR MEMBER OF ASSESSOR’S STAFF________________________________ DATE_____________
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