22
State Tax Form 96-4
The Commonwealth of Massachusetts
Assessors’ Use only
Revised 7/2017
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 later.
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
If yes, wer
e 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 $
Date Voted/Deemed Denied
Certificate No.
Date Cert./Notice Sent
Exemption: Clause
FILING THIS FORM DOES NOT STAY THE COLLECTION OF YOUR TAXES
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
SHREWSBURY
VETERAN
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
YesDid you own the property on July 1, 2020 ? No
2020 ? Yes
B. EXEMPTION STATUS. Check the status that applies to you and complete the questions that follow.
VETERAN
VETERAN’S SPOUSE
Yes
No
If no, where does the veteran reside?_________________________
VETERAN’S/SERVICEMEMBER’S/ NATIONAL
GUARD MEMBER’S SURVIVING SPOUSE or
SERVICEMEMBER’S SURVIVING PARENT
Deceased Veteran’s/Servicemember’s/National Guard member’s
Name ____________________________________________________
If first year of application, attach copy of death certificate.
If you are surviving spouse, have you remarried? Yes No
Date Enlisted/Inducted ____________________________ Date Discharged _______________________________________
Type of Discharge _________________________________
If first year of application, attach copy of discharge papers.
Military Decorations or Awards _______________________________________________________________________________
Did the veteran/service/national guard member live in Massachusetts for at least 6 months before entering the service?
Yes No If no, list places and dates where veteran or member lived during the last 6 years or if deceased, the 6 years before
death (2 years if local option adopted - See Assessors)
Address Dates
Continue list on attachment in same format as necessary.
If yes to any of the next 2 questions and if first year of application, (1) attach documentation from U.S. Dept. of Veterans Affairs,
branch of service and
(2) list above places and dates where surviving spouse has lived during the last 6 years (2 years if local option
adopted See Assessors)
Is the servicemember or national guard member missing in action and presumed dead? Yes No
Was the proximate cause of the veteran’s, servicemember’s or national guard member’s death due to an active duty injury
or illness? Yes No
If yes to next question and first year of application, attach Certificate of Disability from U.S. Dept. of Veterans Affairs or branch of
service.
Does the veteran have a 100% disability rating for service-connected blindness? Yes No
If yes to any of the next 3 questions and
If first year of application, attach Certificate of Disability from U.S. Dept. of Veterans Affairs or branch of service.
If exemption granted previously, attach certificate only if disability rating is 100% or has changed.
Does the veteran have a service-connected disability? Yes No
Has the veteran acquired “specially adapted housing?” Yes No
Is the veteran a paraplegic? Yes No
GO ON TO SECTION C
C. 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.
Veterans Name ___________________________________________
Was the property the veteran’s domicile as of July 1, _____2020__?
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 servicemember,
national guard member or veteran who
died from active duty injury or illness
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 personal representative of the
estate, or trustee under the will, 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.
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