17 41
State Tax Form 96-1
The Commonwealth of Massachusetts
Assessors’ Use only
Revised 11/2016
Date Received
Application No.
Name of City or Town
Parcel Id.
Return to: Board of Assessors
Must be filed with assessors on or before April 1,
or 3 months after actual (not preliminary) tax bills are
mailed for fiscal year if lat
er.
INSTRUCTIONS: Complete the following. Please print or type.
A. IDENTIFICATION. Complete this section fully.
Name of Applicant ________________________________________________________________________________________
Marital Status ________________________________
No. Street City/Town Zip Code
Location of Property:
Mailing Address
(If different)
No. of Dwelling Units: 1 2 3 4 Other
Did you own the property on July 1, ? Yes No
If yes, were you: Sole Owner Co-owner with Spouse Only
Co-owner with Others
Was the property subject to a trust as of July 1,
No
If yes, please attach trust instrument including all schedules.
Have you been granted any exemption in any other city or town (MA or other) for this year? Yes No
If yes, name of city or town ________________________________ Amount exempted $
DISPOSITION OF APPLICATION (ASSESSORS’ USE ONLY)
Ownership
GRANTED
Assessed Tax $
Occupancy
DENIED
Exempted Tax $
Status
DEEMED DENIED
Adjusted Tax $
Income
Assets Board of Assessors
Date Voted/Deemed Denied
Certificate No.
Date Cert./Notice Sent
Exemption: Clause Date:
FILING THIS FORM DOES NOT STAY THE COLLECTION OF YOUR TAXES
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
SHREWSBURY
SENIOR
FISCAL YEAR 2021 APPLICATION FOR STATUTORY EXEMPTION
General Laws Chapter 59, § 5
THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION
(See General Laws Chapter 59, § 60)
Telephone Number _________________________
Legal Residence (Domicile) on July 1, 2020
2020
2020
? Yes
B. EXEMPTION STATUS. Complete the questions that follow.
SENIOR 70 OR OLDER (65 or older by local option- See Assessors)
Date of Birth
If first year of application, attach copy of birth certificate.
Have you owned and occupied the property as your domicile for at least 11 years?
(6 years if local option under Clause 41C½ adopted - See Assessors)
Yes No
If no, list the other properties you owned and/or occupied during the past 11 years (6 years
if local option under Clause 41C½ adopted - See Assessors.)
Address Dates Owned Occupied
Continue list on attachment in same format as necessary.
C. GROSS RECEIPTS FROM ALL SOURCES IN PRECEDING CALENDAR YEAR. Complete this section. Copies of
your federal and state income tax return, and other documentation, may be requested to verify your income.
Applicant & Spouse Co-owner(s) &
Spouse(s)
Retirement Benefits (Social Security, Railroad, Federal, MA & Political Subdivisions)...
Other Pensions and Retirement Allowances....................................................................... …..
Wages, Salaries and other Compensation ........................................................................... …..
Net Profits from Business, Profession or Property Rental ................................................ …..
Interest and Dividends .......................................................................................................... …..
Other Receipts (Capital Gains, Public Assistance, etc.)..................................................... …...
TOTALS
D. VALUE OF ALL PROPERTY OWNED ON JULY 1 THIS YEAR. Complete this section. Documentation may be
requested to verify your assets.
Real Estate
Assessed Valuation
Amount Due on Mort
gage
Value
Domicile
Other
Personal Estate
Bank Accounts: Name & Address of Bank
Stocks, Bonds, Securities, etc.: Description & Amount
Motor Vehicles & Trailers: Year, Make & Model
Other Non-exempt Personal Property: Kind & Description
TOTAL
E. SIGNATURE. Sign here to complete the application.
This application has been prepared or examined by me. Under the pains and penalties of perjury, I declare that to the
best of my knowledge and belief, this return and all accompanying documents and statements are true, correct and
complete.
Signature Date
If signed by agent, attach copy of written authorization to sign on behalf of taxpayer.
TAXPAYER INFORMATION ABOUT PERSONAL EXEMPTIONS
PERSONAL EXEMPTIONS. You may be eligible to reduce all or a portion of the taxes assessed on your
domicile if you meet the qualifications for one of the personal exemptions allowed under Massachusetts law.
Qualifications vary, but generally relate to age, ownership, residency, disability, income or assets.
You may be eligible for an exemption if you fall into any of these categories:
Legally blind person
Veteran with a service-connected disability
Surviving spouse of a servicemember or
national guard member who died in combat
or from combat injury or disease
Surviving spouse
Minor child of a deceased parent
Senior citizen age 70 and older (65 and older
by local option)
More detailed information about the qualifications for each exemption may be obtained from your board of
assessors.
WHO MAY FILE AN APPLICATION. You may file an application if you meet all qualifications for a personal
exemption as of July 1. You may also apply if you are the administrator or executor of a person who qualified
for a personal exemption on July 1.
WHEN AND WHERE APPLICATION MUST BE FILED. Your application must be filed with the assessors on
or before April 1, or 3 months after the actual bills were mailed for the fiscal year, whichever is later. An
application is filed when (1) received by the assessors on or before the filing deadline, or (2) mailed by United
States mail, first class postage prepaid, to the proper address of the assessors, on or before the filing deadline,
as shown by a postmark made by the United States Postal Service. THIS DEADLINE CANNOT BE
EXTENDED OR WAIVED BY THE ASSESSORS FOR ANY REASON. IF YOUR APPLICATION IS NOT
TIMELY FILED, YOU LOSE ALL RIGHTS TO AN EXEMPTION AND THE ASSESSORS CANNOT BY LAW
GRANT YOU ONE.
PAYMENT OF TAX.
Filing an application does not stay the collection of your taxes. In some cases, you must
pay all preliminary and actual installments of the tax when due to appeal the assessors’ disposition of your
application. Failure to pay the tax when due may also subject you to interest charges and collection action.
To avoid any loss of rights or additional charges, you should pay the tax as assessed. If an exemption is granted
and you have already paid the entire year’s tax as exempted, you will receive a refund of any overpayment.
ASSESSORS DISPOSITION. Upon applying for an exemption, you may be required to provide the assessors
with further information and supporting documentation to establish your eligibility. The assessors have 3
months from the date your application is filed to act on it unless you agree in writing before that period
expires to extend it for a specific time. If the assessors do not act on your application within the original or
extended period, it is deemed denied. You will be notified in writing whether an exemption has been granted
or denied.
APPEAL. You may appeal the disposition of your application to the Appellate Tax Board, or if applicable, the
County Commissioners. The appeal must be filed within 3 months of the date the assessors acted on your
application, or the date your application was deemed denied, whichever is applicable. The disposition notice
will provide you with further information about the appeal procedure and deadline.
INFORMATION NEEDED IN FILING FOR EXEMPTIONS
PLEASE ENCLOSE WITH YOUR APPLICATION THE FOLLOWING
INFORMATION (FOR ALL OWNERS/CO-OWNERS):
CLAUSE 41C ($1,000) WITH INCOME AND ASSETS GUIDELINES.
COPIES OF:
1. INCOME TAX RETURNS FROM PREVIOUS YEAR (2019), INCLUDING
ALL SCHEDULES
IF YOU DO NOT FILE AN INCOME TAX RETURN PLEASE FILL OUT
THE ENCLOSED FORM 4506-T AND MAIL IT TO THE ADDRESS ON
THE BACK OF THE FORM. PLEASE DO NOT HAVE THE
TRANSCRIPT MAILED DIRECTLY TO THIS OFFICE.
PLEASE ALSO PROVIDE THE ASSESSORS OFFICE WITH:
2. JULY 1
ST
, 2020 BANK STATEMENT, FOR ALL ACCOUNTS
(INCLUDING IRA, CD, STOCKS/BONDS ETC).
3. SOCIAL SECURITY STATEMENTS (Form SSA-1099) FOR CALENDAR
YEAR 2019
4. PENSION STATEMENTS FOR CALENDAR YEAR 2019.
5. FIRST TIME APPLICANTS MUST PROVIDE COPY OF BIRTH
CERTIFICATE (EXCEPT SURVIVING SPOUSE APPLICANTS WHO
MUST PROVIDE A COPY OF THE DEATH CERTIFICATE).
6. IF THE PROPERTY IS IN A TRUST, WE NEED A COPY OF THE TRUST
DOCUMENTS INCLUDING THE SCHEDULE OF BENEFICIARIES.
CLAUSE 17D ($175) ELDERLY AND WIDOWS #3 AND #4 ARE NOT NEEDED.
BOARD OF ASSESSORS
100 MAPLE AVE
SHREWSBURY MA 01545
508-841-8501
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