State Tax Form 99 - Financial Hardship Fiscal Year - Application For Property Tax Deferral
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4The Commonwealth of Massachusetts
Assessors’ Use only
State Tax Form 99
Date Received
Issued 7/2009
Application No.
Parcel Id.
Name of City or Town
FINANCIAL HARDSHIP
FISCAL YEAR _______ APPLICATION FOR PROPERTY TAX DEFERRAL
General Laws Chapter 59, § 5, CLAUSE 18A
THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION
(See General Laws Chapter 59, § 60)
Return to:
Board of Assessors
Must be filed with assessors on or before December 15 or 3
months after actual (not preliminary) tax bills are mailed for
fiscal year if later. Tax Deferral and Recovery Agreement
(Form 99-1) must accompany application unless already on file
and persons with interest in property remain the same.
INSTRUCTIONS: Complete all sections that apply. Please print or type.
A. IDENTIFICATION. Complete this section fully.
Name of Applicant _________________________________________
Occupation __________________________________
Telephone Number _________________________
Marital Status ________________________________
Legal Residence (Domicile) on July 1, _________
Mailing Address
(If different)
No.
Street
City/Town
Zip Code
Location of Property:
No. of Dwelling Units: 1
2
3
4
Other
Did you occupy the property on July 1, __________ and for the prior 10 years?
Yes
No
If no, list the other properties you occupied during the past 10 years.
Address
Dates
Continue list on attachment in same format as necessary.
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
GRANTED
Assessed tax
$
Occupancy
DENIED
Deferred tax
$
Status
DEEMED DENIED
Adjusted tax
$
Financial condition
Board of Assessors
Date voted/Deemed denied
Certificate No.
Date Cert./Notice sent
Date:
FILING THIS FORM DOES NOT STAY THE COLLECTION OF YOUR TAXES
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
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