Form 41 - Fy2016 Wellesley Application For Senior 65 And Older Statutory Exemption Page 2
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1
2B. EXEMPTION STATUS.
Date of Birth:
(If first year of application, attach copy of birth certificate.)
Have you owned and occupied the property as your domicile for at least 5 years?
Yes
If no, list the other properties you owned and / or occupied during the past 10 years.
Address
Dates
Owned
Occupied
________________________________________________________
_______________________
______
______
________________________________________________________
_______________________
______
______
C. GROSS RECEIPTS (ALL INCOME TAXABLE AND NON-TAXABLE) FROM PRECEDING CALENDAR YEAR.
A copy of your 2014 federal tax return is requested to verify your income.
APPLICANT
CO-OWNER(S)
AND SPOUSE
AND SPOUSE
Retirement benefits (Social Security, Railroad,
$_______________
$_______________
Federal, Mass. and Political Subdivisions)
$_______________
$_______________
Other pensions and retirement allowances
Wages, salaries and other compensation
$_______________
$_______________
Net profits from business or profession
$_______________
$_______________
Interest and dividends
$_______________
$_______________
$_______________
$_______________
Other receipts (rent, capital gains, etc.)
$_______________
$_______________
TOTALS
D. VALUE OF ALL PROPERTY OWNED ON JULY 1 THIS YEAR.
PLEASE COMPLETE BELOW WHERE SHADED
Documentation is requested to verify your assets.
R
Previous Year Assessed Value
Amount due on mortgage
Value
E
Domicile:
A
$______________________
$______________________
$______________
L
Other Property:
$______________________
$______________________
$______________
Bank accounts:
Name and address of bank
Value
_____________________________________________________________________________________
$_____________
_____________________________________________________________________________________
$_____________
P
E
_____________________________________________________________________________________
$_____________
R
S
O
Stocks, bonds, securities, etc.:
N
Description and amount owned
Value
A
______________________________________________________________________________________
$_____________
L
______________________________________________________________________________________
$_____________
Other non-exempt personal property:
Type
Description
Value
___________________________
___________________________________________________
$_____________
TOTAL
$_____________
E. SIGNATURE. Sign here to complete the application.
This application has been prepared or examined by me. Under 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.
________________________________________________________________________
______________________________
Your signature
Date
C. SIGNATURE. Sign here to complete the application.
If signed by agent, attach copy of written authorization to sign on behalf of taxpayers.
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