Form FM05-3 "Military Personnel Application" - New York City, New York City

What Is Form FM05-3?

This is a legal form that was released by the New York City Department of Finance - a government authority operating within New York City. The form may be used strictly within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 16, 2012;
  • The latest edition provided by the New York City Department of Finance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FM05-3 by clicking the link below or browse more documents and templates provided by the New York City Department of Finance.

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Download Form FM05-3 "Military Personnel Application" - New York City, New York City

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NYC DEPARTMENT OF FINANCE
COLLECTIONS DIVISION
G G
M M I I L L I I T T A A R R Y Y P P E E R R S S O O N N N N E E L L A A P P P P L L I I C C A A T T I I O O N N
TM
Finance
Mail to: NYC Department of Finance, Collections Division, 59 Maiden Lane, 28th floor, New York, NY 10038
Instructions: Use this form if you are an active member of the military or a reservist ordered to report for induction or military service
(”service member”); or if you are a service memberʼs spouse, registered domestic partner or dependent (unmarried child under the
age of 18 or unmarried child ages 18-23 in school full-time, or anyone else for whom the service member provided at least 50% of
their support for 180 days before the date of this application). Please see Finance Memorandum 05-3, July 12, 2005, for further details.
S E C T I O N I - A P P L I C A N T I N F O R M A T I O N
Complete item 1 and any other item in this section that is applicable. Please print clearly.
1. Service memberʼs Name: _______________________________________________________________________
Address: ____________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
2. Dependentʼs Name: ___________________________________________________________________________
Address: ____________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
3. Agent/Representative name:_____________________________________________________________________
Address: ____________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
4. Indicate the name of the service member for which you have the Power of Attorney:
(A copy of the Power of Attorney must be attached)__________________________________________________
ʼ
SERVICEMEMBER
S NAME
S E C T I O N I I - M I L I T A R Y S T A T U S
Select and complete Items 1 or 2 and Items 3 through 5 below.
1.
The service member is active and serving full time duty in the Army, Navy, Marine Corps, Air Force, Coast
K
Guard or a member of the National Guard of the United States of America.
2.
The service member is a reservist who has been ordered to report for induction or military service.
K
Indicate the branch and order/commission date: ________________________
________________
BRANCH
DATE
3.
I have attached a copy of the Order or Commission instructing the individual service member to report for military service.
K
4. List rank of service member: ____________________________________________________________________
PRINT RANK
5. Indicate the service memberʼs social security number:
Visit Finance at nyc.gov/finance
FM05-3 Affidavit Rev. 10.16.12
NYC DEPARTMENT OF FINANCE
COLLECTIONS DIVISION
G G
M M I I L L I I T T A A R R Y Y P P E E R R S S O O N N N N E E L L A A P P P P L L I I C C A A T T I I O O N N
TM
Finance
Mail to: NYC Department of Finance, Collections Division, 59 Maiden Lane, 28th floor, New York, NY 10038
Instructions: Use this form if you are an active member of the military or a reservist ordered to report for induction or military service
(”service member”); or if you are a service memberʼs spouse, registered domestic partner or dependent (unmarried child under the
age of 18 or unmarried child ages 18-23 in school full-time, or anyone else for whom the service member provided at least 50% of
their support for 180 days before the date of this application). Please see Finance Memorandum 05-3, July 12, 2005, for further details.
S E C T I O N I - A P P L I C A N T I N F O R M A T I O N
Complete item 1 and any other item in this section that is applicable. Please print clearly.
1. Service memberʼs Name: _______________________________________________________________________
Address: ____________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
2. Dependentʼs Name: ___________________________________________________________________________
Address: ____________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
3. Agent/Representative name:_____________________________________________________________________
Address: ____________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
4. Indicate the name of the service member for which you have the Power of Attorney:
(A copy of the Power of Attorney must be attached)__________________________________________________
ʼ
SERVICEMEMBER
S NAME
S E C T I O N I I - M I L I T A R Y S T A T U S
Select and complete Items 1 or 2 and Items 3 through 5 below.
1.
The service member is active and serving full time duty in the Army, Navy, Marine Corps, Air Force, Coast
K
Guard or a member of the National Guard of the United States of America.
2.
The service member is a reservist who has been ordered to report for induction or military service.
K
Indicate the branch and order/commission date: ________________________
________________
BRANCH
DATE
3.
I have attached a copy of the Order or Commission instructing the individual service member to report for military service.
K
4. List rank of service member: ____________________________________________________________________
PRINT RANK
5. Indicate the service memberʼs social security number:
Visit Finance at nyc.gov/finance
FM05-3 Affidavit Rev. 10.16.12
S E C T I O N I I I - T A X P R O V I S I O N R E Q U E S T
Select and complete the applicable tax provision section(s) from the list below:
1. Real Property Tax
The service member owns and occupies the property, for dwelling, professional, business or agricultural
K
purposes, or the property is occupied by the service memberʼs dependents or employees for such purposes
during the period of the service memberʼs service.
a. Indicate Borough: ______________________________ Block: _________________ Lot: ________________
b. Property Address: __________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
2.
Tax Warrants
K
a. Indicate service memberʼs social security number:
b. Indicate New York City tax warrants that have been docketed against the service member:
Warrant Number
Type of Tax
Tax Period
Docket Date
_______________________ ______________________ _____________________ _____________________
_______________________ ______________________ _____________________ _____________________
_______________________ ______________________ _____________________ _____________________
_______________________ ______________________ _____________________ _____________________
3.
Environmental Control Board Judgments
K
a. Indicate the New York City Environmental Control Judgments that have been docketed against the service member:
Violation Number
Property Address
# ____________________
________________________________________________________________
STREET
CITY
STATE
ZIP CODE
# ____________________
________________________________________________________________
STREET
CITY
STATE
ZIP CODE
ATTACH ADDITIONAL PAGE IF NECESSARY
4.
Parking Violation Judgments
K
a. Indicate service memberʼs license plate number(s):
Plate #: _____________________ Plate #: ______________________
Plate #: ______________________
ATTACH ADDITIONAL PAGE IF NECESSARY
S E C T I O N I V - C E R T I F I C A T I O N
I agree and I am aware that any intentional false statement on this application would subject me to criminal prosecution and acknowledge that the
Department of Finance is acting in reliance on the statements that I have made in this application in deciding whether to apply the ben-
}
efits of the law to the enforcement of the judgments, to the applicable interest rates or to the real property tax in question.
______________________________________
_____________________________________
_____________
PRINT NAME OF APPLICANT
SIGNATURE
DATE
STATE OF NEW YORK
ss.:
COUNTY OF
________________________________________
On the _____ day of ___________, 20____, before me personally came _______________________________________
to me known, who, being by me duly sworn did depose and say that (s)he resides at:
______________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
and that (s)he executed this application.
Sworn to before me this ________ day of
_________________________, 20______.
__________________________________
NOTARY PUBLIC
NOTARY STAMP OR SEAL HERE
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