STATE TAX FORM 128-5C G.L. Ch. 59, Sec. 5C
TAX BILL NO.___________
THE COMMONWEALTH OF MASSACHUSETTS
Fiscal 2011 Do not write in this space
TOWN OF TISBURY Date application received:
APPLICATION FOR RESIDENTIAL EXEMPTION
MUST BE FILED WITHIN 3 MONTHS AFTER THE DATE THE TAX BILL WAS SENT.
The undersigned being aggrieved by the failure to receive a residential exemption on real estate
situated at _______________________________________________________________ for fiscal year _______
hereby applies for such an exemption.
STATEMENT OF FACTS
Name(s) of record owner(s) ____________________________________________________________________
Name of applicant ____________________________________________________________________________
Was this real estate owned and occupied by you as your principal residence on January 1, 2010?
Date Acquired:___________________________ How acquired: ____________________________________
BY PURCHASE, INHERITANCE, FORECLOSURE, GIFT, ETC
List location of any other residential real estate owned by you.
Have you ever received a residential exemption in any other city or town? If so, give the address of the
property and the year(s) in which the exemption was received. __________________________________________
Will you receive or have you applied for a residential exemption in any other city or town for the fiscal year
to which this application relates? ______ If so, give the name of the city or town and the address of the
property to which the exemption relates.
Signing the form under the penalties of perjury has the legal effect of swearing under oath to the truthfulness
of the information contained herein: All items on this form must be completed. In addition to other
sanctions provided by law, intentional misrepresentation of facts in this application may result in cancellation
of this exemption.
SUBSCRIBED THIS ___________________day of ________________, ______UNDER THE PENALTIES OF PERJURY
Signature of Applicant _______________________________________PHONE NUMBER___________________
Post Office Address ____________________________________________________________________________
THE FILING OF THIS APPLICATION DOES NOT STAY THE COLLECTION OF YOUR TAX
THIS FORM APPROVED BY COMMISSIONER OF REVENUE
FOR ASSESSORS’ RECORDS
Sent _________________________for hearing____________held______________with_____________________________
DATE DATE DATE NAME
Exemption _____________________________________ in previous year $____________ Page__________ Line________
EXEMPTION ALLOWED ON THE TOTAL
TO THE EXTENT OF $_____________________________ VALUATION OF $_________________under General Laws,
____________________________________ BOARD OF ASSESSORS
Date ____________, _____ ____________________________________ OF TISBURY