HomeMy Public PortalAboutBLIND (37) EXEMPTION37
State Tax Form 96-3
Revised 7/2017
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The Commonwealth of Massachusetts
Name of City or Town
Assessors' Use only
Date Received
Application No.
Parcel Id.
BLIND
FISCAL YEAR APPLICATION FOR STATUTORY EXEMPTION
General Laws Chapter 5, § 5
THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION
(See General Laws Chapter 59, § 60)
1
Return to: Board of Assessors
Must be filed with assessors on or before Apr111, 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
Telephone Number Marital Status
Legal Residence (Domicile) on July 1, Mailing Address Of different)
No. Street City/Town Zip Code Location of Property: No. of Dwelling Units: 102r -13E 4 ❑Other
Did you own the property on Jul 1, ? Yes ElNoEl
If yes, were you: Sole Owner LJ 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 1 J GRANTED❑
Occupancy ❑ DENIED ❑
Status - ❑ DEEMED DENIED
Income
Assets
Date Voted/Deemed Denied
11
Certificate No.
Date Cert./Notice Sent
Exemption: Clause
Assessed Tax $
Exempted Tax $
Adjusted Tax $
Board of Assessors
Date:
FILING THIS FORM DOES NOT STAY THE COLLECTION OF YOUR TAXES
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
B. EXEMPTION STATUS. Complete the questions that follow.
Were you legally blind as of July 1, ? Yes U No U
Are you registered with Mass. Commission for the Blind? Yes E No ❑
If yes, give Certificate Number Date Registered
If no, attach a letter from your doctor indicating status as of July 1.
Attach copy of certificate.
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
If signed by agent, attach copy of written authorization to sign on behalf of taxpayer.
Date