Fillable Statutory Exemption Application Fy2020 (Town of Hopedale)

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Statutory Exemption Application Fy2020 (Town of Hopedale)

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State Tax Form 96
The Commonwealth of Massachusetts
Revised 7/2019
Name of City or Town
SENIOR -- SURVIVING SPOUSE OR MINOR -- VETERAN -- BLIND
FISCAL YEAR _______ APPLICATION FOR STATUTORY EXEMPTION
General Laws Chapter 59, § 5
THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION
(See General Laws 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 that apply. If you qualify under more than one category, you will receive the
exemption that provides the greatest amount of assistance. Please print or type.
A. IDENTIFICATION. Complete this section fully.
Name of Applicant ________________________________________________________________________________________
Telephone Number _________________________
Marital Status ________________________________
Legal Residence (Domicile) on July 1, _________
_____________________________________________________
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, ? 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 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
HOPEDALE
2020
B. EXEMPTION STATUS. Check each status that applies to you and complete the questions that follow.
BLIND PERSON
Were you legally blind as of July 1, ________? Yes No
Are you registered with Mass. Commission for the Blind? Yes No
If yes, give Certificate Number Date Registered Attach copy of certificate.
If no, attach a letter from your doctor indicating status as of July 1.
IF NO OTHER STATUS APPLIES TO YOU, GO ON TO SECTION E
VETERAN
VETERAN’S SPOUSE
Veteran’s Name ___________________________________________
Was the property the veteran’s domicile as of July 1, ________?
Yes No
If no, where does the veteran reside? ________________________
VETERAN’S/SERVICEMEMBER’S/ NATIONAL
GUARD MEMBER’S SURVIVING SPOUSE or
SERVICEMEMBER’S SURVIVING PARENT
(or GUARDIAN if local option adopted – See
Assessors)
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 3 years or if deceased, the 3 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 3 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 documentation from U.S. Dept. of Veterans Affairs or branch of service.
Has the servicemember or veteran ever been a prisoner of war? 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
IF NO OTHER STATUS APPLIES TO YOU, GO ON TO SECTION E
SURVIVING SPOUSE
Deceased Spouse’s Name
Date of Death
Have you remarried? Yes No If yes, date of remarriage ____________
MINOR WITH PARENT DECEASED
Deceased Parent’s Name
Date of Death
If first year of application, attach a copy of death certificate.
Are you a surviving spouse or a minor child of a firefighter or a police officer killed in the line of duty?
Yes No
IF NO, AND NO OTHER STATUS APPLIES TO YOU, GO ON TO SECTION D
If yes, and this is the first year of application, provide circumstances of death.
GO ON TO SECTION E
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.
GO ON TO SECTION C
C. GROSS RECEIPTS FROM ALL SOURCES IN PRECEDING CALENDAR YEAR. Complete this section if you are a senior.
Copies of your federal and state tax income returns, 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
GO ON TO SECTION D
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Statutory Exemption Application Fy2020 (Town of Hopedale)

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Completed 14 July 2020

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