State Tax Form 128-5i -Application For Small Commercial Exemption
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1
2The Commonwealth of Massachusetts
Assessors’ Use Only
State Tax Form 128-5I
Date Received
10/2000
Application No.
Parcel Id.
Name of City or Town
APPLICATION FOR SMALL COMMERCIAL EXEMPTION
FISCAL YEAR _______
General Laws Chapter 59 §5I
THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION
(See General Laws Chapter 59 §60)
Return to:
Board of Assessors
Must be filed with assessors within 3 months after actual
(not preliminary) tax bills are mailed for fiscal year.
INSTRUCTIONS: Complete BOTH sides of application. Please print or type.
A. TAXPAYER INFORMATION. Complete this section fully.
Name(s) of assessed owner:
Name(s) and status of applicant (if other than assessed owner) __________________________________________________
Subsequent owner (aquired title after January 1) on
___________________________________________________________
Administrator/executor.
Mortgagee.
Lessee.
Other. Specify.
Mailing address
Telephone No. (
)
No.
Street
City/Town
Zip Code
B. PROPERTY IDENTIFICATION. Complete using information as it appears on tax bill.
Tax bill no.
Assessed valuation $
Location (Street Address) ___________________________________________________________________________________
Parcel identification no. (map-block-lot)
Land area
DISPOSITION OF APPLICATION (ASSESSORS’ USE ONLY)
Occupancy
GRANTED
Assessed tax
$
Employment
DENIED
Exempted tax $
Valuation
DEEMED DENIED
Adjusted tax
$
Board of Assessors
Date voted/Deemed denied
Certificate No.
Date Certificate/Notice sent
Date:
FILING THIS APPLICATION DOES NOT STAY THE COLLECTION OF YOUR TAXES.
TO AVOID LOSS OF APPEAL RIGHTS OR ADDITION OF INTEREST AND COLLECTION CHARGES, THE TAX SHOULD BE PAID AS ASSESSED.
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
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