Clause 17D Exemption Form Step 1 of 2 50% This is an online form. You can easily complete the form from any desktop computer, tablet or mobile device and submit it online. You will automatically receive a confirmation of receipt. If there are attachments, you can even do those online as well. If you do not have all the required documentation, the submission will not go through. Don't forget that if you have any questions or requests please don't hesitate to let us know. By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored. Name(Required) Address(Required) Phone(Required) Parcel Id(Required) Telephone Date of Birth(Required) Marital Status(Required) Status(Required) Surviving Spouse Over 70 Minor whose Parent is Deceased Date of Death Did you own and occupy the above property as your principle residence as of July 1, 2021?(Required) Yes No Is the property subject to a trust as of July 1, 2021?(Required) Yes No Please provide a copy of the “Schedule of Beneficiaries” from the trust documents. Indicate the value of the following on July 1, 2021. Do not include the value of your primary residence or qualified retirement accounts and annuities. Real estate owned in other jurisdictions must be reported on SCHEDULE A on the reverse side of this form. COPIES OF YOUR FINANCIAL STATEMENTS AS OF JULY 1, 2021 MUST ACCOMPANY THIS APPLICATION. THE APPLICATION WILL NOT BE PROCESSED WITHOUT THE STATEMENTS. Amount in bank accounts (Savings, checking, certificate of Deposit)(Required)Value of Stocks, Bonds and Securities(Required)Value of other Personal Property (Ex. Boat, Recreational Vehicle)(Required)TotalIs the property larger than three (3) dwelling units?(Required) Yes No Is there any commercial/business use of this property?(Required) Yes No As of July 1, 2021 are (were) you the record owner of real estate in any other jurisdiction?(Required) Yes No If YES to any of the above questions, please complete Schedule A on the back of this form. Your signature is required on the back of this form. Thank you Schedule A-Clause 17D Complete this schedule if you answered yes to any of the previous questions. 1. If your principal place of residence exceeds 3 dwelling units and/or has commercial use, please answer the following:a. Total Assessed Value of Property: b. Number of Units: If the applicant holds less than full ownership, indicate ownership percentage 2. If you own real estate other than your principal residence within or outside Massachusetts, please answer the following:a. Location b. If applicant holds less than full ownership, indicate ownership percentage c. Total Assessed Value of Property: 9. I have read this return. Under the pains and penalties of perjury, I declare that to the best of my knowledge and belief, the return is correct and complete. 10. By requesting consideration for exemption, I hereby authorize the City of Brockton Assessing Department to make any and all inquiries to any party regarding any bank account, whether held in my name individually, as trustee or agent, or against which I have the power to draw, whether or not my name appears. Signature(Required)Date(Required) MM slash DD slash YYYY Upload Document(s)(Required)Max. file size: 50 MB.Please provide copies of your financial statements, as well as a copy of the Schedule of Beneficiaries if the property is subject to a trust.