State Tax Form 96-6 - Senior-Surviving Spouse Or Minor Application For Statutory Exemption - 2009 Page 2

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B. EXEMPTION STATUS. Check each status that applies to you and complete the questions that follow.
Deceased Spouse’s Name
SURVIVING SPOUSE
Date of Death
Have you remarried?
Yes
No
If yes, date of remarriage ____________
Deceased Parent’s Name
MINOR WITH PARENT DECEASED
Date of Death
If first year of application, attach a copy of death certificate.
Yes
No
Are you a surviving spouse or a minor child of a firefighter or a police officer killed in the line of duty?
IF NO, AND NO OTHER STATUS APPLIES TO YOU, GO ON TO SECTION D
If yes, and this is the first year of application, provide circumstances of death.
GO ON TO SECTION E
Date of Birth
SENIOR 70 OR OLDER (65 or older by local option- See Assessors)
If first year of application, attach copy of birth certificate.
Have you owned and occupied the property as your domicile for at least 11 years?
Yes
No
(6 years if local option under Clause 41C½ adopted - See Assessors)
If no, list the other properties you owned and/or occupied during the past 11 years (6 years
if local option under Clause 41C½ adopted - See Assessors.)
Address
Dates
Owned
Occupied
Continue list on attachment in same format as necessary.
GO ON TO SECTION C
C. GROSS RECEIPTS FROM ALL SOURCES IN PRECEDING CALENDAR YEAR. Complete this section if you are a
senior. Copies of your federal and state income tax returns, and other documentation, may be requested to verify your
income.
Applicant &
Co-owner(s) &
Spouse
Spouse(s)
Retirement Benefits (Social Security, Railroad, Federal, MA & Political Subdivisions).…..
Other Pensions and Retirement Allowances....................................................................... .…..
Wages, Salaries and other Compensation ........................................................................... .…..
Net Profits from Business, Profession or Property Rental ................................................ .…..
Interest and Dividends .......................................................................................................... …...
Other Receipts (Capital Gains, Public Assistance, etc.) ..................................................... …...
TOTALS
GO ON TO SECTION D

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