Form Cp-4 - Application For Community Preservaton Act Exemption - Low Income Person
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4The Commonwealth of Massachusetts
Assessors’ Use only
CP-4
Date Received
7/2009
Application No.
Parcel Id.
Name of City or Town
LOW INCOME PERSONS - LOW OR MODERATE INCOME SENIORS
FISCAL YEAR _______ APPLICATION FOR COMMUNITY PRESERVATION ACT EXEMPTION
General Laws Chapter 44B
Return to:
Board of Assessors
INSTRUCTIONS: Complete all sections. Please print or type.
A. IDENTIFICATION. Complete this section fully.
Name of Applicant _________________________________________________________________________________
Telephone Number ____________________
Marital Status _________________________
Were you 60 years or older on January 1, _______? Yes
No
If yes and first year of application, please attach copy of birth certificate.
Legal residence (domicile) on January 1, _____
_________________________________________________________
No.
Street
City/Town
Zip Code
Mailing address (if different) _________________________________________________________________________
No.
Street
City/Town
Zip Code
Location of property: __________________________________
No. of dwelling units: 1
2
3
4
Other ____
Did you own the property on January 1, _____? Yes
No
If yes, were you:
Sole owner
Co-owner with spouse only
Co-owner with others
Was the property subject to a trust as of January 1, _____? Yes
No
If yes, please attach trust instrument including all schedules.
Have you been granted any exemption in any other city or town (MA or other) for this fiscal year? Yes
No
If yes, name of city or town _____________________________ Type of exemption ____________________________
B. 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, the application 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.
YOU MUST ALSO COMPLETE SCHEDULES C - F ON FOLLOWING PAGES
FILING THIS APPLICATION DOES NOT STAY THE COLLECTION OF YOUR SURCHARGE.
TO AVOID INTEREST AND COLLECTION CHARGES, YOU MUST PAY SURCHARGE AS BILLED BY DUE DATE.
IF EXEMPTION IS GRANTED AND SURCHARGE IS PAID IN FULL, REFUND WILL BE MADE.
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
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