State Tax Form 96-1 - Senior Application For Statutory Exemption

State Tax Form 96-1 - Senior Application For Statutory Exemption - 2007 Page 2

B. EXEMPTION STATUS. Complete the questions that follow.

Date of Birth

SENIOR 70 OR OLDER (65 or older by local option- See Assessors)

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?

Yes

(6 years if local option under Clause 41C½ adopted - See Assessors)

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

C. GROSS RECEIPTS FROM ALL SOURCES IN PRECEDING CALENDAR YEAR. Complete this section. Copies of

your federal and state income tax return, 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

D. VALUE OF ALL PROPERTY OWNED ON JULY 1 THIS YEAR. Complete this section. Documentation may be

requested to verify your assets.

Assessed Valuation

Amount Due on Mortgage

Value

Real Estate

Domicile

Other

Personal Estate

Bank Accounts: Name & Address of Bank

Stocks, Bonds, Securities, etc.: Description & Amount

Motor Vehicles & Trailers: Year, Make & Model

Other Non-exempt Personal Property: Kind & Description

TOTAL

State Tax Form 96-1 - Senior Application For Statutory Exemption - 2007 Page 2