Fillable Commonwealth of Massachusetts Form CP-4 Application for Community Preservation Act Exemption

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Commonwealth of Massachusetts Form CP-4 Application for Community Preservation Act Exemption

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The Commonwealth of Massachusetts Form CP-4 Application for Community Preservation Act Exemption form is 4 pages long and contains:

  • 2 signatures
  • 14 check-boxes
  • 155 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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CP-4
The Commonwealth of Massachusetts
Assessors’ Use only
Revised 11/2016
Date Received
Application No.
Name of City or Town
Parcel Id.
LOW INCOME PERSONS - LOW OR MODERATE INCOME SENIORS
FISCAL YEAR _______ APPLICATION FOR COMMUNITY PRESERVATION ACT EXEMPTION
General Laws Chapter 44B
THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION
(See General Laws Chapter 44B, § 3 and Chapter 59, § 60)
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 later.
INSTRUCTIONS: Complete all sections. Please print or type.
A. IDENTIFICATION. Complete this section fully.
Name of Applicant _________________________________________________________________________________
Telephone Number ____________________ Marital Status _________________________
Were you 60 years or older on January 1, _______? Yes No
If yes and first year of application, please attach copy of birth certificate.
Legal residence (domicile) on January 1, _____ _________________________________________________________
No. Street City/Town Zip Code
Mailing address (if different) _________________________________________________________________________
No. Street City/Town Zip Code
Location of property: __________________________________
No. of dwelling units: 1 2 3 4 Other ____
Did you own the property on January 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 January 1, _____? Yes 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 fiscal year? Yes No
If yes, name of city or town _____________________________ Type of exemption ____________________________
B. 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, the application 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.
YOU MUST ALSO COMPLETE SCHEDULES C - F ON FOLLOWING PAGES
FILING THIS APPLICATION DOES NOT STAY THE COLLECTION OF YOUR SURCHARGE.
TO AVOID INTEREST AND COLLECTION CHARGES, YOU MUST PAY SURCHARGE AS BILLED BY DUE DATE.
IF EXEMPTION IS GRANTED AND SURCHARGE IS PAID IN FULL, REFUND WILL BE MADE.
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
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C. HOUSEHOLD MEMBERS. List all members of your household on January 1 and provide requested information.
Please list any members who are 18 and older and not full time students last. Documentation may be requested
to verify information provided.
Full Name
(First, Middle, Last)
Relationship to
Applicant
Age as of 1/1
Occupation or
School Grade
1. ____________________________________ _____________________ _____________ __________________
2. ____________________________________ _____________________ _____________ __________________
3. ____________________________________ _____________________ _____________ __________________
4. ____________________________________ _____________________ _____________ __________________
5. ____________________________________ _____________________ _____________ __________________
6. ____________________________________ _____________________ _____________ __________________
Continue list on attachment, in same format, as necessary.
D. HOUSEHOLD OUT OF POCKET MEDICAL EXPENSES DURING PRECEDING CALENDAR YEAR. List total
medical expenses incurred by all household members during calendar year before January 1 that were not paid
by or reimbursed by employer, public or private health insurance or other third party. Includes amounts paid in
health insurance premiums, co-payments, deductibles and other out of pocket expenses. Documentation may be
requested to verify expenses claimed.
TYPE OF EXPENSE
Total Out of Pocket for
Preceding Calendar Year
Health insurance premiums $ _________________________
Doctors $ _________________________
Hospitals $ _________________________
Diagnostic tests $ _________________________
Prescription drugs $ _________________________
Medical equipment $ _________________________
Other $ _________________________
TOTAL OUT OF POCKET
$ _________________________
E. HOUSEHOLD GROSS INCOME DURING PRECEDING CALENDAR YEAR. List income received from all sources for each member of household 18 and
older and not full time student during calendar year before January 1. Please list members in same order as shown in Schedule C above. Copies of federal
and state income tax returns may be requested to verify income reported for each household member.
TYPE OF INCOME
Applicant
Name
____________________
Member 1
Name
_____________________
Member 2
Name
______________________
Member 3
Name
______________________
Wages, salaries, other compensation $ $ $ $
Social Security
Other pension/retirement benefits
Interest/dividends
Rental income
Net profits from business or profession
Capital gains
Alimony
Child support
Public assistance
Unemployment compensation
Disability compensation
Other (specify):
TOTAL GROSS INCOME - MEMBERS
$ $ $ $
TOTAL GROSS INCOME -
HOUSEHOLD
$
Continue list on attachment, in same format, as necessary.
F. CO-OWNERS’ HOUSEHOLD GROSS INCOME DURING PRECEDING CALENDAR YEAR.
Does Schedule E above include the gross income of all co-owners of the property as of January 1, _____? Yes No
If no, a Schedule C, D and E must be attached for each co-owner not included.
DISPOSITION OF APPLICATION (ASSESSORS’ USE ONLY)
Age
Ownership
Occupancy
Applicant’s Gross Income $
Dependent Deduction $
Medical Deduction $
Applicant’s CPA Income $
Co-
owner 1 Gross Income
$
Dependent Deduction $
Medical Deduction $
Co-owner 1 CPA Income $
Co-
owner 2 Gross Income
$
Dependent Deduction $
Medical Deduction $
Co-owner 2 CPA Income $
GRANTED
DENIED
Assessed surcharge $
Exempted surcharge $
Adjusted surcharge $
BOARD OF ASSESSORS
Date voted
Certificate number
Date certificate/Notice sent
Date:
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Commonwealth of Massachusetts Form CP-4 Application for Community Preservation Act Exemption

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Completed 13 May 2020

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