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City of Northampton, Massachusetts
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Eligibility Application for Senior Property Tax Work Off Program 2017

  1. City of Northampton Senior Property Tax Work Off Program Eligibility Application

    This application is not open for public inspection.

  2. THIS FORM MUST BE SUBMITTED WITH THE APPLICATION

  3. Date: __________________________

  4. Name of Applicant: ___________________________________________

  5. Telephone: _________________

  6. Address: ______________________________________ Property ID: _____________________________

  7. Social Security No: __________________ Marital Status: __________ Date of Birth: _________________

  8. Annual Gross Income: $ __________for all members of your household._

  9. Please provide a copy of your 2015* Federal Tax Return - Pages 1 & 2

  10. If you did not file a Federal Tax Return for 2015, please provide copies from all income sources during calendar year 2015 such as: Social Security statement for 2015; copy of bank statement for 2015; copy of pension or retirement statement for 2015; copy of interest or dividend statement for 2015; other income statements.

  11. * Tax return filing will be verified with the Internal Revenue Service

  12. Maximum Work Off Credit Allowed per Household is $1,000.

  13. This application has been examined by me. 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.

  14. Signature: _______________________________________________ Date: _______________________

  15. Disposition of Applicant (Assessors' use only)

  16. Reviewed by: _______________________________________ Date: ____________________

  17. Leave This Blank: