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2. Participant Application Senior Property Tax Work Off Program - January 1, 2019 - October 31, 2019
4. First Name*
5. Last Name*
7. Address1*
8. City*
9. State*
11. Zip*
12. Applicants Email
13. Tel. No.
15. Name & Phone # of Emergency Contact*
17. Property Address for which you are seeking a credit:
19. Part A: Eligibility requirements. Please answer the following questions either yes or no.
21. Are you at leaset 60 years of age?

    1. Yes

    1. No
22. Are you a Northampton homeowner or the current spouse of a Northampton homeowner?

    1. Yes

    1. No
24. Are you a Veteran?

    1. Yes
    2. No
25. Is your Northampton home your primary residence?

    1. Yes

    1. No
26. Do you own any other properties in MA or any other state?

    1. Yes

    1. No
28. Do you own and occupy the property for which you are seeking a credit?

    1. Yes

    1. No
29. Are you a current City of Northampton employee?

    1. Yes

    1. No
33. Part B. Qualifications
35. List your skills and talents. Please list at least three (3) skills.
36. Please list your former occupation(s):
38. Please check off areas of proficiency:

    1. Computer Basics
    2. Excel
    3. Intermediate Computer
    4. Word Processing
    5. Computer Advanced
    6. Other
40. Please check off comfort levels:

    1. Comfortable dealing with the public
    2. Comfortable in busy environment
    3. Comfortable answering the telephone
    4. Other:
42. Do you have any physical restrictions? (example: hearing limitation, vision loss, inability to sit or stand for a period of time, limited range of motion, unable to lift, etc.) Please explain.
44. Do you prefer to work outdoors if a position were available?

    1. Yes

    1. No
45. Do you drive?

    1. Yes

    1. No
47. Do you have transportation to a work site?

    1. Yes

    1. No
49. Please note dates, days and time you are unable to participate, or any scheduling restrictions.
53. (You will be notified of Acceptance/Non-Acceptance in January 2019 for placement thereafter.)
55. By typing your name in, I attest that your Northampton residence is your primary residence, and if I qualify for the Senior Property Tax Work Off Program, I understand that what I earn can only be applied as a credit to my City of Northampton Property Tax.
    Please type your full name and today's date.
57. We thank you for completing this portion of the Senior Tax Credit Program Application! If you have any questions or concerns, please contact Northampton Senior Services at 413-587-1228
61. FOR OFFICE USE ONLY
63. Disposition of Application

    1. Granted

    1. Denied
65. PLACEMENT:
67. Department:
69. Position Title:
71. NON-PLACEMENT:
73. Please indicate reason for denial:
75. Staff Signature:
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit Submit and Print

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