2012 Tax Exemption Form by 4qZ843

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									TAX EXEMPTIONS WILL ONLY BE APPROVED TO THOSE APPLICANTS WHO
PROVIDE THE TREASURER A COPY OF THEIR INCOME TAX ASSESSMENT FOR 2011

                                              (Please Print Clearly)
NAME:                             ___________________________________________________________
MAILING ADDRESS:                  ___________________________________________________________
CIVIC NUMBER:                     ___________________________________________________________
TELEPHONE NUMBER: ___________________________________________________________
CUSTOMER NUMBER:                  _________________ ASSESSMENT NUMBER: _________________

                     APPLICATION FOR EXEMPTION AS GRANTED UNDER
                      SECTION 69 OF THE MUNICIPAL GOVERNMENT ACT

The Council of the Region of Queens Municipality has directed by Administrative Policy Number 9 that
an exemption not exceeding $200.00 from taxation will be granted for the taxation year April 1, 2012 to
March 31, 2013 pursuant to Section 69 of the Municipal Government Act upon residential property
owned by a person. No tax exemption shall be provided unless the request is made prior to
February 28, 2013 for this fiscal year.

The following guidelines are mandatory in order to qualify for the above exemption:

(1)     Was the total income from all sources for you and all family members residing in the household
        $19,500.00 or LESS in the year January 1, 2011 to December 31, 2011? (Monthly income
        would calculate to $1,625.00)                                   YES______ NO______

(2)     Are you a resident of the Region of Queens Municipality?                   YES______        NO______

(3)     Are you living in the property this exemption is requested for?            YES______        NO______

(4)     Have you attached a copy of your 2011 Income Tax Assessment? YES______                      NO______

(5)     How many people over the age of 19 reside at this residence?               _____________________

NOTE: Family members include common law relationships; income from all sources including the following:
Old Age Security, Guaranteed Income Supplement, Canada Pension, Company Pensions, Investment Income,
Interest Income, etc. Income not included is any allowance to the War Veterans Allowance Act (Canada) or
pension paid pursuant to the Pension Act (Canada).

Where two or more persons, one or more of whom are entitled to an exemption, are by any interest the owners of
taxable property together, the person so entitled shall be entitled only to that portion of the amount of the
exemption that the amount of his assessment with respect to the property bears to the total assessment for the
whole property, and where the owners are not separately assessed for their several interests in the property, then to
that portion determined by the assessor, whose determination shall be final.

Return completed application to:                     Region of Queens Municipality
                                                     249 White Point Road
                                                     P.O. Box 1264
                                                     Liverpool, NS B0T 1K0

I HEREBY CERTIFY THAT THE FOREGOING INFORMATION IS CORRECT AND I
REALIZE IT IS UNLAWFUL TO MAKE ANY FALSE STATEMENTS.


SWORN           TO       before       me        at
                                                                   Signature of Applicant
______________________ in the County of
Queens and the Province of Nova Scotia this
_________ day of ________________,
2012.
                                                                   FOR OFFICE USE ONLY:

____________________________________                               Assessed Value:              _______________
Mayor, Councillor, or Commissioner                                 District Number              _______________
of the Supreme Court of Nova Scotia.

								
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