Name of Municipality ______________________________________
1. NAME OF APPLICANT: __________________________________________ 2. PRESENT ADDRESS: _____________________________________________ 3. AGE: ________ 4: TOTAL INCOME FOR: __________; $____________ YEAR
I, ___________________________________, HEREBY MAKE APPLICATION TO ______________________________________ FOR EXEMPTION OR REMISSION FROM MUNICIPAL TAXES FOR __________ . (YEAR)
MY CLAIM FOR EXEMPTION OR REMISSION OF MUNICIPAL TAXES IS BASED UPON THE FOLLOWING: ( PLEASE CHECK APPROPRIATE SPACE) A. INSUFFICENT INCOME : __ B. NONRESIDENCE : __ C. OTHER : __ , PLEASE EXPLAIN:_________________________ ___________________________________________________________________ ___________________________________________________________________
DATED AT ______________________________ THIS ________________ (town) (day) OF _____________________________ A.D. 20_____. (month) (year)
____________________________________________ SIGNATURE OF APPLICANT
NOTE: A COPY OF YOUR INCOME RETURN FOR THE PREVIOUS YEAR MUST ACCOMPANY THIS FORM.
FOR COUNCIL USE ONLY EXEMPTION GRANTED:_______________ EXEMPTION REFUSED:________________ , REASON FOR REFUSAL:_________________ _______________________________________________________________________________ DATE: ______________________________
________________________________________________ SIGNATURE OF COUNCIL REPRESENTATION