State Tax Form 96-4 - Veteran Application For Statutory Exemption

State Tax Form 96-4 - Veteran Application For Statutory Exemption - 2005 Page 2

B. EXEMPTION STATUS. Check the status that applies to you and complete the questions that follow.

Veteran’s Name _____________________________________________

VETERAN

VETERAN’S SPOUSE

Deceased Veteran’s Name

VETERAN’S SURVIVING SPOUSE/ PARENT

If first year of application, attach copy of death certificate.

If you are surviving spouse, have you remarried? Yes

Date Enlisted/Inducted

Date Discharged

If first year of application, attach copy of discharge papers.

Type of Discharge

Military Decorations or Awards

Did the veteran live in Massachusetts at least 6 months before entering the service?

Yes

If no, list places and dates where the veteran was domiciled during the last 6 years. (2 years if local option adopted- See Assessors)

Address

Dates

Was the veteran killed during military service?

Yes

If yes, date of death __________________________

Does the veteran have a service-connected disability?

Yes

If yes and first year of application, attach Certificate of Disability from U.S. Dept. of Veterans Affairs or branch of service.

If yes and exemption granted previously, attach certificate only if disability rating is 100% or has changed.

Has the veteran acquired “special adapted housing?” Yes

Is the veteran currently working?

Yes

If no, when did veteran last work?_______________________

Is the veteran a paraplegic? Yes

C. SIGNATURE. Sign here to complete the application.

This application has been prepared or examined by me. Under the pains and penalties of perjury, I declare that to the

best of my knowledge and belief, this return and all accompanying documents and statements are true, correct and

complete.

Signature

Date

If signed by agent, attach copy of written authorization to sign on behalf of taxpayer.

State Tax Form 96-4 - Veteran Application For Statutory Exemption - 2005 Page 2