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2. City of Northampton Senior Property Tax Work Off Program Eligibility Application
   This application is not open for public inspection.
4. THIS FORM MUST BE SUBMITTED WITH THE APPLICATION
6. Name of Applicant:
7. Phone:
9. Mailing Address:
10. Email Address:
12. Name & Phone Number of Emergency Contact
14. Property Address for which you are seeking credit
15. Property ID (if known)
19. PART A: ELIGIBILITY REQUIREMENTS
    Please answer the following questions:
21. Are you at least 60 years of age?

    1. YES

    1. NO
22. Are you a Veteran?

    1. YES

    1. NO
24. Are you a Northampton homeowner or current spouse of a Northampton homeowner?

    1. YES

    1. NO
25. Is your Northampton home your primary residence?

    1. YES

    1. NO
27. Do you own any other properties in MA or any other state?

    1. YES

    1. NO
28. Do you own and occupy the property for which you are seeking credit?

    1. YES

    1. NO
30. Are you a City of Northampton employee?

    1. YES

    1. NO
34. PART B: Qualifications
    Please list your skills & talents. Please list at least three skills.
36. Skill or Talent
37. Skill or Talent
39. Skills or Talent
40. Skill or Talent
42. Skill or Talent
43. Skill or Talent
45. Please check off areas of proficiency:
47. COMPUTER

    1. Basic
    2. Intermediate
    3. Advanced
    4. Word Processing
    5. Spreadsheets
    6. Other
49. CUSTOMER SERVICE SKILLS

    1. Comfortable dealing with public
    2. Comfortable answering the phone
    3. Comfortable in a busy environment
    4. Other_____________________________
51. Do you have any physical or medical restrictions? (For example: hearing limitations, vision loss, inability to sit or stand for an extended period, limited range of motion, etc.) Please explain.
53. Do you prefer to work outdoors if a positions is available?

    1. YES

    1. NO
55. Do you drive?

    1. YES

    1. NO
57. Do you have transportation to a work site?

    1. YES

    1. NO
59. Please list any days, time that you are unable to participate:
61. PART C: SENIOR ELIGIBILITY FINANCIAL INFORMATION
63. Tax Filing Status
64. Date of birth
65. Annual Gross Income
    (For all members of your household. See income eligibility guidelines.)
67. Please provide a copy of your 2021* Federal Tax Return - Pages 1 & 2
69. 2021 Federal Tax Return- Pages 1 & 2
71. If you did not file a Federal Tax Return for 2021, please provide copies from all income sources during calendar year 2021 such as: Social Security statement for 2021; copy of bank statement for 2021; copy of pension or retirement statement for 2021; copy of interest or dividend statement for 2021; other income statements.
73. Other Income Sources
75. * Tax return filing will be verified with the Internal Revenue Service
77. Maximum Work Off Credit Allowed per Household is $1,500. This document must be signed.
81. By signing below, I attest that my Northampton residence is my primary residence, and if I qualify for the Senior Property Tax Work-Off Program, I understand that what I earn can only be applied as a credit to my City of Northampton property tax. Under the pains and penalties of perjury, I declare that to the best of my knowledge and belief, it and all accompanying documents and statements are true, correct, and complete.
83. Signature:
    Typing your name substitutes as signature for online submittal purposes.
84. Date:
88. ASSESSOR'S OFFICE USE ONLY
91. SENIOR SERVICES USE ONLY
94. PLACEMENT
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit Submit and Print

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