HomeMy Public PortalAboutCPA Exemption ApplicationCP-4
Revised 11/2016
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The Commonwealth of Massachusetts
Name of City or Town
Assessors' Use only
Date Received
Application No.
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
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,
Mailing address (if different)
No. Street
Location of property:
No. Street
Marital Status
City/Town Zip Code
Did you own the property on January 1, ? Yes
If yes, were you: Sole owner
No
No. of dwelling units: 1
Co-owner with spouse only
City/Town
2 3
4
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
If yes, name of city or town Type of exemption
Zip Code
Other
No
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
If signed by agent, attach copy of written authorization to sign on behalf of taxpayer.
Date
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
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.
1.
2.
3.
4.
5.
6.
Full Name
(First, Middle, Last)
Continue list on attachment, in same format, as necessary.
Relationship to
Applicant
Age as of 1/1
Occupation or
School Grade
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.
Total Out of Pocket for
TYPE OF EXPENSE 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
If no, a Schedule C, D and E must be attached for each co-owner not included.
No
DISPOSITION OF APPLICATION (ASSESSORS' USE ONLY)
Age
Ownership
Occupancy
o
o
o
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
o
o
Date voted
Certificate number
Date certificate/Notice sent
$
$
$
BOARD OF ASSESSORS
Date: