Tisbury Massachusetts
51 Spring Street, P.O. Box 1239, Vineyard Haven, MA 02568
ph: (508) 696-4200
Residential Exemption Application
STATE TAX FORM 128-5C                                                           G.L. Ch. 59, Sec. 5C
TAX BILL NO.___________                                                         

RESIDENTIAL EXEMPTION
THE COMMONWEALTH OF MASSACHUSETTS
Fiscal  2011                                                                              Do not write in this space
                                        TOWN OF TISBURY                                   Date application received:
                                    508-696-4206
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  _______
                NO.             STREET
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?

YES_____        NO_____

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



Notice                                                  Hearing
Sent _________________________for hearing____________held______________with_____________________________
                DATE                            DATE            DATE                    NAME


                        
Exemption _____________________________________ in previous year $____________ Page__________ Line________


EXEMPTION DISALLOWED___________________________________________________________________________
                                                                REASON


EXEMPTION ALLOWED                               ON THE TOTAL
TO THE EXTENT OF $_____________________________ VALUATION OF $_________________under General Laws,





____________________________________

                                       ____________________________________     BOARD OF ASSESSORS

Date ____________, _____               ____________________________________     OF TISBURY