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2. I,
   Last name/first name/middle initial
3. Rank
4. Branch
6. Date of Birth
7. hereby claim an exemption from person property taxation in
9. accordance with provisions of §574 of the Service Members' Civil Relief Act of 1940, as amended. Having
11. been duly sworn, I depose the following in support of my claim:
13. Phone Number
15. 1. On or after October 1,
16. year
17. (hereinafter referred to as the
19. assessment date), I was an active duty member of the United States Armed forces, attached to the
21. following duty station in Connecticut:
24. 2. I reported to my present duty station in Connecticut on or about
    2. I reported to my present duty station in Connecticut on or about
26. and I anticipate that my present tour of duty assignment at that station will completed on or about
    and I anticipate that my present tour of duty assignment at that station will completed on or about
28. 3. My presence in Connecticut on the assessment date was solely as a result of my official military orders.

    1. Yes
    2. No
30. If "No," please explain:
32. 4. My home record or permanent address as shown in in my military records is in the State of:
34. 5. I have retained my domicile in said State without interruption throughout my service in the Armed Forces.

    1. Yes
    2. No
36. If "No," please explain:
38. 6. It is now, and was on the assessment date, my intention to return to the State of my domicile upon my separation or retirement from the United States Armed Forces.

    1. Yes
    2. No
40. If "No," please explain:
42. 7. On the assessment date, I lived in the State of Connecticut at:
44. Address
46. City
47. State
48. Zip Code
50. 8. My current address is the same as on the assessment date.

    1. Yes
    2. No
52. If "No," current address:
54. Address
56. City
57. State
58. Zip Code
60. 9. I am (and was) married on the assessment date.

    1. Yes
    2. No
62. If "Yes," spouse's name:
64. 10. On the assessment date, I (and/or my spouse) owned the personal property described below, which
66. was located in the City/Town of
68. , Connecticut.
70. Note: With respect to "Ownership," please enter the following code(s), as applicable:
    S - For property owned solely by serviceman;
    SP - For property owned solely by serviceman's spouse; or
    J - For property jointly owned by serviceman and his/her spouse.
72. Motor Vehicle
    Including unregistered snowmobiles
74. Year, Make, Model
75. State & Plate Number
76. Ownership
94. Signature of Affiant
96. Phone Number
97. Email
99. Signature of Notary Public
101. Subscribed and sworn to me
     Subscribed and sworn to me
102. My commission expires:
     My commission expires:
Leave This Blank:


105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit Submit and Print

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