Form 126 - Motor Vehicle Excise Abatement Application - The Commonwealth Of Massachusetts - Worthington Board Of Assessors
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1
2The Commonwealth of Massachusetts
Assessors’ Use only
State Tax Form 126
Date Received
Revised 4/2000
Worthington
Application No.
Name of City or Town
MOTOR VEHICLE EXCISE ABATEMENT APPLICATION
CALENDAR YEAR _______
General Laws Chapter 60A
Return to: Worthington Board of Assessors
Must be filed with assessors by December 31 of
the calendar year following the excise year (or 30
days after the bill is issued if that date is later)
INSTRUCTIONS: Complete BOTH sides of application. Please print or type.
A. TAXPAYER INFORMATION.
Name(s) (as shown on bill
Telephone No. (
)
Address (as shown on bill)
No.
Street
City/Town
Zip Code
Mailing address (if different)
No.
Street
City/Town
Zip Code
B. BILL INFORMATION. Complete using information as it appears on tax bill.
Tax year
Plate/registration number
Tax date
Vehicle identification number
Issue date
Vehicle year
Bill number
Model
C. SIGNATURE.
Subscribed under the penalties of perjury
Signature of applicant
Date
YOU MUST ALSO COMPLETE SECTION D ON REVERSE SIDE
DISPOSITION OF APPLICATION (ASSESSORS’ USE ONLY)
Calendar year _____________
Assessed excise $ _____________
Board of Assessors
Bill number _______________
Abatement
$ _____________
Valuation _________________
Adjusted excise $ _____________
Months assessed ___________
Certificate number ____________
Date
FILING THIS APPLICATION DOES NOT STAY THE COLLECTION OF YOUR EXCISE.
TO AVOID INTEREST, CHARGES AND COLLECTION ACTION, YOU MUST PAY EXCISE AS BILLED BY THE DUE DATE.
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
** CONTINUED ON OTHER SIDE **
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