Northern Potter School District Occupational - Tax Form D

To Whom it May Concern:

I attest that I became disabled on and I ask that my school occupational

assessment be reduced to 0 for the        year and all subsequent tax years. Further, I attest that should I return to either part-time or full-time work I will notify the Tax Collector.

This form must be returned or mailed to your respective Tax Collector by December 15 of the current tax year. Your Tax Collector address and contact information is located on your tax bill.

Each February for the current tax year the Northern Potter School Board of Directors will be presented with a List of Abatement requests to be approved.

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Applicant's Signature                                                Tax Collector's Signature at                                                                         Approval Date

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Applicant's Twp or Borough                                        Date of Approval