FOR PROPERTY TAX EXEMPTION

FOR THE ELDERLY

All information will be held strictly confidential and for use of the town in determining eligibility for exemption only.

This form will be signed under penalty of perjury.

Applicant's Name _______________________________ Date of Birth ___________

Residential Address ____________________________________________________

List ALL real estate owned, whether in the Town of Raymond or elsewhere ___________
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List other assets (including the amount of their full value), including bank accounts, certificates of deposit, stocks, bonds, cash on hand, vehicles, investments, etc.
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Income (before any deductions are made):____________________________

Wages/Compensation Social Security Payments:_______________________

Pension Payments Income from Retirement Plans:______________________

Payments received from Trusts Income on Investment Earnings:____________

Other (please explain)_____________________________________________________


Applicant Signature ________________________________

Date ____________________________________________

Please provide the previous year's Federal Income Tax Form (or a statement advising that you no longer are required to file), the previous year's State Interest & Dividend Tax Form, and any Pension eligibility forms or award letters that you may have received. These items will be returned to you upon a decision being made relative to your application.


OFFICE USE ONLY: Date Rec'd _________________ Accepted/Denied: ________ Date: __________

Documentation Rec'd: POA _______ POI _______ POV ________ POR(5) ___________

MAP _______ LOT ________

NOTES: ___________________________________________________________________________________
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