Form Ma Va 40 41 – Fill Out and Use This PDF

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Form Ma Va 40 41 PDF Details

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Question	Answer
Form Name	Form Ma Va 40 41
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	fillable 41 pennsylvania, ma 40 va, ma va form 40 41, ma va form 40

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DISABLED VETERANS’

REAL ESTATE TAX EXEMPTION PROGRAM

APPLICATION FOR EXEMPTION FROM REAL PROPERTY TAXES

Every blank must have an entry or the application will be returned. No determination can be made until all required information is provided.

Important Facts to Remember when Applying:

●Type or print clearly all requested information

●The affidavit at the end of the application must be sworn to in front of a notary public or a Jurat stamp holder and must be processed through your local County Director for Veterans’ Affairs

●Application must be date stamped by your County Tax Assessor’s Office

Documents Required:

●Military Discharge (DD Form 214) showing wartime service

●Marriage Certificate (spouse application only)

●Veteran’s Death Certificate (spouse application only)

Income Verification Documentation Required:

●1040 Federal Income Tax Return

●VA Compensation Rating

●Employment Income (most recent W-2)

●Social Security Benefit Statement (Form SSA-1099)

●Interest Income (Form 1099-INT)

●Dividend Income (Form 1099-DIV)

●Distribution from Pensions, Annuities, Retirement or Profit Sharing Plans, IRA’s, Insurance Contracts, etc. (Form 1099-R)

Expense Documentation Required

●Supporting Documentation of Expenses (based on income level)

Privacy Act Statement. Authority: 51 Pa.C.S. Chapter 89.

Principal Purpose: This application form is the primary source of information to determine eligibility for the Real Property Tax Exemption Program for certain disabled veterans and their unmarried surviving spouses. Routine Use: The information you provide will be used to review and determine your eligibility for exemption for real property taxes under Article 8, Section 2(c) of the Pennsylvania Constitution and 51 Pa.C.S. Ch. 89. The information may be provided to federal, state and local agencies, including your local taxing authorities, in connection with review of your application.

Voluntary Disclosure: Disclosure of information on these forms, including the Social Security Number of applicant is voluntary. However, failure to provide your Social Security Number may result in a delay in the review of your application or an inability for the Department of Military and Veterans Affairs to obtain verification information.

Instructions for Completing the Application

General Information:

●If you are a veteran check the block for “veteran”

●If you are a surviving spouse of a qualified veteran, who has not remarried, check the block “spouse”

Section A: Veteran - Complete all information in this section.

Section B: Spouse – Complete all information in this section.

Section C: Veteran’s Disability Rating and Exemptions – Check all blocks that apply.

Section D: Dependent Members of Your Immediate Family Residing in the Household - List the names of all dependents, their relationship to the veteran, and their date of birth. Children

may be counted as dependents only until they are 18 years old unless they are in school on a full-time basis and under the age of 24, or they are unable to care for themselves.

.Section E: Property Information - Check appropriate block.

Section F: Income – List the gross income before any deductions for taxes, expenses or costs. Yearly interest and/or dividend income earned from savings accounts, stocks, bonds, annuities, trust funds or other securities are also required. No adjustments to, or deductions from, income will be authorized in determining applicability of the rebuttable presumption. Submit required income verification documentation.

Income defined from Title 43 § 5.22 as follows: wages, bonuses, commissions, income from self- employment, support money, cash public assistance and relief; the gross amount of pensions or annuities, including railroad retirement benefits; benefits received under the Social Security Act except Medicare benefits; benefits received under state unemployment insurance laws and veterans’ disability payments; interest received from the federal or state government or an instrumentality or political subdivision thereof; realized capital gains; rentals; workmen's compensation and the gross amount of loss-of-time insurance benefits and proceeds except the first $5,000 of the total of death benefit payments; and gifts of cash or property other than transfers by gift between members of a household in excess of a total of $300. This term does not include surplus food or other relief in kind supplied by a governmental agency. Income from savings accounts and bonds shall be included as well as interest received from investments.

Section G: Expenditure Documentation - If your annual income exceeds $81,340, this section must be completed. All financial entries on the application require documentation in the form of a copy of a bill, receipt, or invoice for expenses incurred within the last twelve months.

Only one recent bill is necessary for those expenses that recur each month, i.e. mortgage. Copies of checks, handwritten lists, and personal computer generated lists are not acceptable. Receipts and bills should be organized by category.

Section H: Affidavit - This section must be dated, signed and sworn in front of a notary public or a Jurat stamp holder (County Director for Veterans’ Affairs office).

VA Form 3288 – Highlighted areas Only, must be completed and form must be submitted with application.

MA-VA Form 40/41 and MA-VA Form 40ss/41

Rev. JANUARY 2011

Commonwealth of Pennsylvania

Department of Military & Veterans’ Affairs

Office of the Deputy Adjutant General for Veterans’ Affairs

Ft. Indiantown Gap, Annville, PA 17003-5002

Date stamp by your County Tax Assessment Office required here. This date will be your official request for exemption.

APPLICATION FOR DETERMINATION OF FINANCIAL NEED FOR REAL PROPERTY TAX EXEMPTION

APPLICANT:

Veteran

Spouse

(Veterans Social Security Number is Required)

APPLICANT DATA

V.A. Claim #

A	Veteran’s Last Name		First	Name	M/I		Social Security #

	Current	Address You	Occupy				Birth	Date: (Mo)	(Day)	(Year)

	Mailing Address

	City	State		Zip	County		Home Phone
						(		)
B	Spouse’s Last Name		First	Name	M/I		Social Security #

	Current	Address You	Occupy				Birth	Date: (Mo)	(Day)	(Year)

	City	State		Zip	County		Home Phone
						(		)

ELIGIBILITY CRITERIA

1.	Is the veteran rated 100% total and permanently disabled
	by the U.S. Department of Veterans’ Affairs?	YES	NO
2.	Is the veteran’s disability service-connected?	YES	NO
3.	Does the veteran have wartime service?	YES	NO

4. Exemptions: (check all blocks which apply)

	100% Disabled Blind	Paraplegic Double Amputee Age 65 and Over If Living with you
VETERAN:
SPOUSE:

D		DEPENDENT DATA

List members of your immediate family residing in the household except the spouse listed in section B.

NAME	RELATIONSHIP	BIRTH DATE

PROPERTY INFORMATION

1.	Is the property you occupy titled in your name solely?	YES
2.	Is the property titled jointly in the veteran and spouse’s names?	YES
3.	Is the property occupied by the applicant and spouse as principal dwelling?	YES
4.	Do you own any other real estate that you do not occupy?	YES
	-If yes to question 4, provide annual amount of rent in the appropriate block in Section F.
	-Address of rental property: ______________________________________________
5.	Do you own assets in excess of $750,000.00 excluding the dwelling in which you reside?	YES
6.	How much property does your dwelling reside on? __________ acres

NO NO NO NO

General Rule. Except as otherwise provided in these guidelines, an applicant for the disabled Veterans’ Real Estate Tax Exemption program who meets all other eligibility criteria for the exemption, including financial need, will be considered as having a need for the exemption to be applied to the entire parcel or lot on which the principal dwelling of the applicant is situated.

Exceptions to General Rule. The general rule described in aforementioned paragraph shall not apply in the following circumstances:

a. To any portion of the parcel or lot in excess of five (5) acres in area, provided that an applicant shall be given the opportunity to provide information that he or she has an individualized need for the real estate tax exemption for greater than five acres. In determining the five-acre area for which an applicant has need for the exemption, the Commission shall consider the area most contiguous to the principal dwelling taking into account the natural and manmade features on the parcel or lot including roads, waterways, steep slopes and other regular and ordinary boundaries.

b. To any portion of the parcel or lot being rented to another person or entity for residential, business or other purposes.

c. To any portion of the parcel or lot being occupied or used for purposes unrelated to the principal dwelling of the applicant.

7. Request a waiver to exemptions to General Rule for property:

YES

Justifications: (Required if requesting waiver)_________________________________________________

__________________________________________________________________________

INCOME SOURCE

Do you affirm that your gross annual income is less than $81,340?

YES

Source of Information	Required Documents	Veteran’s Income	Spouse’s Income
Source of Information	(Prior Calendar Year)
	(Prior Calendar Year)
V.A. Compensation	VA Compensation Rate Form
Social Security (NOTE 1)	SSA – Form 1099
Gross Employment Income (NOTE 1)	Form W–2
Civil Service Annuity (NOTE 1)	Form 1040 Tax Return
Retirement/Pension (NOTE 1)	Form 1099 – R
Blind/Paralyzed Pension
Rent from Property (NOTE 1 & 2)	Lease Agreement/Form 1040
Gifts, Inheritance, and Death Benefits
(NOTE 1 & 2)
Yearly Interest (NOTE 1 & 2)	Form 1099 – INT
Yearly Dividends (NOTE 1 & 2)	Form 1099 – DIV
Yearly Capital Gains (NOTE 1 & 2)	Form 1040 Tax Return
Other Income (NOTE 1 & 2)	Form 1040 Tax Return
TOTAL INCOME		$	$

Note 1: Please attach supporting documentation of income.

Note 2: If an account/ property/ etc. is jointly owned with your spouse, place 50% of the earned income in veteran’s income column and 50% in spouse’s income column,. If solely owned, place earned income in the appropriate column.

EXPENDITURE DOCUMENTATION

IF YOUR ANNUAL INCOME IS $81,340 OR LESS, DO NOT COMPLETE SECTION G

MONTHLY EXPENSES

1. Mortgage Payment _______________________ (Indicate below costs included in mortgage payment)

Principal__________ Interest__________ Mortgage Ins.__________ Taxes__________

2.Educational Costs________________________________________________

3.Car Payment ____________________________________________________

4.Real Estate Tax __________________________________________________

5.Medical Bills for Legal Dependents__________________________________

6.Average Monthly Electric Power ____________________________________

7.Average Monthly Home Heating Fuel_________________________________

8.Trash Removal____________________________________________________

9.Domestic Help ____________________________________________________

10.Water ____________________________________________________________

11. Sewage __________________________________________________________

12. Telephone ________________________________________________________

PLEASE ATTACH ALL SUPPORTING DOCUMENTATION IN THE FORM OF RECEIPTS AND/OR BILLS

AFFIDAVIT

READ THIS NOTICE BEFORE SIGNING

By signing this application, the applicant certifies that the information provided is true and correct to the best of his knowledge, information and belief. The law provides severe penalties including fines and imprisonment for making false statements on official forms such as this application for Real Property Tax Exemption.

THIS AFFIDAVIT MUST BE SIGNED AND SWORN TO BY THE APPLICANT:

COMMONWEALTH OF PENNSYLVANIA	:
COUNTY OF ________________________	ss:

________________________________, being first duly sworn, deposes and says that he/she (or a person acting under

his/her direction) has prepared this application for Real Property Tax Exemption, that he/she has carefully read this application, that the information contained in the application (both written and printed) are true and correct.

__________________________________		_____________________________________
(WITNESS)		(SIGNATURE OF APPLICANT)
Subscribed and sworn before me this _________day of ___________________, 20_____.
My Commission Expires ___________	_____________________________________________________
(DATE)	(SIGNATURE OF NOTARY PUBLIC or JURAT STAMP HOLDER)

Processed By: ________________________________________________________________

(Signature of County Veterans’ Affairs Director)

FOR OFFICIAL USE	Processed by _______________	_______________
	(Initials)	(Date)

Department of Veterans Affairs

APPLICANT: Only fill out blocks that are highlighted

Form Approved: OMB No. 2900-0025

Respondent Burden: 7.5 minutes

Department of Veterans Affairs

REQUEST FOR AND CONSENT TO RELEASE OF INFORMATION FROM CLAIMANT’S RECORDS

Privacy Act Statement: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, United States Code, and will authorize release of the information you specify. The information may also be disclosed outside VA as permitted by law to include disclosures as stated in the “Notices of Systems of VA Records” published in the Federal Register in accordance with the Privacy Act of 1974.

RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond, to this collection of information unless it displays a valid OMB Control Number, the Privacy Act of 1974 (5 U.S.C. 552a) and VA’s confidentiality statue (38 U.S.C. 5701 as implemented by 38 CFR 1.526 (a) and 38 CFR under any other provision of law). The information requested is approved under OMB Control Number 2900-0025 and is necessary to ensure that the statutory requirements of the Privacy Act and VA’s Confidentiality statute are met.

Responding to this collection of information is voluntary. However, if the information is not furnished, we may not be able to comply with your request. Public reporting burden for this collection of information is estimated to average 7.5 minutes per respondent, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to the VA Clearance Officer (045A4, 810 Vermont Avenue, NW, Washington, DC 20420). SEND COMMENTS ONLY. DO NOT SEND THIS FORM OR REQUESTS FOR BENEFITS TO THIS ADDRESS.

NAME OF VETERAN (Type or print)

		VA FILE NO. (Include prefix)			SOCIAL SECURITY NO.

NAME AND ADDRESS OF ORGANIZATION AGENCY, OR INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

Office of the Deputy Adjutant for Veterans’ Affairs

Bldg S-0-47, FT Indiantown Gap

Annville, PA 17003-5002

Attn: Malinda Jones

	VETERAN’S REQUEST
I hereby request and authorize the Department of Veterans Affairs to		NAME
release the following information from the records identified above
to the organization, agency, or individual named hereon:

INFORMATION REQUESTED (Number each item requested and give the dates or approximate dates - period from and to - covered by each.)

THIS SECTION TO BE FILLED OUT BY U.S. DEPARTMENT OF VETERANS AFFAIRS

The above named veteran has applied for the Pennsylvania Disabled Veterans Real Estate Tax Exemption program. This office needs the following information to determine the eligibility criteria of the Pennsylvania Disabled Veterans Real Estate Tax Exemption program.

1.	Discharged under honorable conditions:		Yes	No	(Circle One)
2.	Wartime service:		Yes	No	(Circle One)
3.	BLIND -Is the veteran's corrected vision 10/200 or less:		Yes	No	(Circle One)
4.	PARAPLEGIC -Loss of use of two or more limbs:		Yes	No	(Circle One)
5.	AMPUTEE -Loss of two or more limbs:		Yes	No	(Circle One)
6.	Does the veteran have a 100% P&T or Permanent 100% IU
	service connected disability rating?		Yes	No	(Circle One)
7.	What is the date the 100% P&T rating became effective?	_______/_______/ _________
8.	What is the veteran’s total compensation amount for the year _________?		$_____________
	If the veteran is deceased, what is the total DIC amount for the year _______?		$_____________
9.	If receiving DIC, was the veteran rated 100% P&T prior to death?	Yes	No	(Circle One)

Signature of US Dept of VA Representative____________________________________________

REMARKS: ____________________________________________________________________

______________________________________________________________________________

PURPOSE (S) FOR WHICH THE INFORMATION IS TO BE USED.

Pennsylvania Disabled Veterans” Real Estate Tax Exemption Program determination (Veteran Benefit under Title 51, Pa.C.S.)

NOTE: Additional information may be listed on the reverse side of this form.

	SIGNATURE OF INDIVIDUAL OR PERSON AUTHORIZED TO SIGN FOR INDIVIDUAL (Attach authority to sign, e.g., POA)			DATE

VA FORM 3288

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In an effort to complete this document, be certain to enter the right information in every blank:

1. You have to fill out the ma va form 40 hbyet 2019 properly, hence be mindful while filling out the sections containing these blank fields:

Step number 1 in filling in ma va form 40 rev january 6 2017

2. Once your current task is complete, take the next step – fill out all of these fields - Is the veteran rated total and, Exemptions check all blocks which, D List members of your immediate, and DEPENDENT DATA with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

DEPENDENT DATA, Exemptions check all blocks which, and Is the veteran rated total and in ma va form 40 rev january 6 2017

3. This subsequent segment should be relatively easy, PROPERTY INFORMATION, Is the property you occupy titled, Address of rental property Do, General Rule Except as otherwise, a To any portion of the parcel or, the opportunity to provide, b To any portion of the parcel or, purposes, c To any portion of the parcel or, the applicant, Request a waiver to exemptions to, and Justifications Required if - all of these form fields must be completed here.

Justifications Required if, the opportunity to provide, and Request a waiver to exemptions to inside ma va form 40 rev january 6 2017

Be extremely mindful when filling out Justifications Required if and the opportunity to provide, because this is the part in which many people make errors.

4. It is time to complete this fourth form section! In this case you will get all these Justifications Required if, INCOME SOURCE, Do you affirm that your gross, Source of Information, VA Compensation Social Security, Required Documents Prior Calendar, VA Compensation Rate Form SSA, Form INT Form DIV Form Tax, Veterans Income, and Spouses Income fields to fill in.

ma va form 40 rev january 6 2017 writing process clarified (step 4)

5. Since you draw near to the finalization of your file, you'll find a few more requirements that have to be satisfied. Notably, TOTAL INCOME, and Note Please attach supporting should be filled out.

ma va form 40 rev january 6 2017 writing process shown (part 5)

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