City of MAP __________ LOT___________
Ellsworth
1 City Hall Plaza, Ellsworth Maine 04605 Assessor's Signature _____________________
Effective date of approval: April 1, ______________
EXEMPTION APPLICATION
Note: Forms filed after April 1st of any year will apply to the subsequent year tax assessment.
Name: ____________________________________________________________________
(first) (middle) (last)
Homestead Street Location: # ___________ Street Name: _________________________
Mailing: ______________________________ City: _______________________________
(If different from above)
State: _____________________ Zip _______________ Phone: ______________________
1. I am a legal resident of the State of Maine Yes or No
2. I declare this house is my permanent place of residence and the ONLY property
I claim as a HOMESTEAD. Yes or No
(Summer camps, vacation homes and or second residences
qualify.)
3. I have owned this property since: (date on deed) Month ______ Day ______ Year ________
3a. 12 months added to the date above would be Month _____ Day______ Year _______
4. The next April 1st date coming after the date above in 3a would be: April 1, ___________.
5. I understand that to qualify I must have owned a home in Maine for the
12 preceding months and it must be my permanent residence. Yes or No
6. If you own, or have owned, a permanent residence prior to this home, please list:
a. Town: _____________________________________.
b. Did you claim a Homestead Exemption there? Yes or No
c. Do you continue to claim a Homestead Exemption there? Yes or No
d. Timeframe of the prior ownership:
1. Date Purchased: Month ______ Day ______ Year _______
2. Date Sold: Month ______ Day ______ Year _______
7. I file a Maine Resident Income Tax Return? Yes or No
8. Do you register your vehicle(s) in Ellsworth? Yes or No
9. The primary residence on my Driver's License is Ellsworth? Yes or No
10. Are you a registered voter in Ellsworth? Yes or No
(if you circled NO to questions 7,8,9, or 10, please explain on back of this form)
I do hereby declare, that the answers to the above are true, correct and complete and I understand that providing false information
is a criminal offense. I do hereby also declare that when and or if I cease or discontinue my permanent residency at this home, I will
contact the Assessor to discontinue this exemption.
Signature: _________________________________________ Date: _______________
(only one signature required)
This form can be submitted in person, by mail, email assessing@ellsworthmaine.gov or fax 207-669-6618
