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The Commonwealth of Massachusetts Assessors’ Use only CP-4 Revised 5/08/2025 Date Received SALEM Application No. Name of City or Town Parcel Id. LOW INCOME PERSONS - LOW OR MODERATE INCOME SENIORS FISCAL YEAR 2026 APPLICATION FOR COMMUNITY PRESERVATION ACT EXEMPTION General Laws Chapter 44B THIS APPLICATION IS NOT OPEN TO PUBLIC INSPECTION (See General Laws Chapter 44B, § 3 and Chapter 59, § 60) INSTRUCTIONS: Complete all sections. Please print or type. A. IDENTIFICATION. Complete this section fully. Marital Status Number Name of Applicant Telephone Were you 60 years or older on January 1, 2025 ? Yes No If yes and first year of application, please attach copy of birth certificate. Legal residence (domicile) on January 1, 2025 No. Street City/Town Zip Code Mailing address (if different) No. Street City/Town Zip Code Location of property: No. of dwelling units: 1 2 3 4 Other Did you own the property on January 1, 2025 ? Yes No If yes, were you: Sole owner Co-owner with spouse only Co-owner with others Was the property subject to a trust as of January 1, 2025 ? Yes No If yes, please attach trust instrument including all schedules. Have you been granted any exemption in any other city or town (MA or other) for this fiscal year? Yes No If yes, name of city or town Type of exemption B. SIGNATURE. Sign here to complete the application. This application has been prepared or examined by me. Under the pains and penalties of perjury, I declare that to the best of my knowledge and belief, the application and all accompanying documents and statements are true, correct and complete. Signature Date If signed by agent, attach copy of written authorization to sign on behalf of taxpayer. YOU MUST ALSO COMPLETE SCHEDULES C - F ON FOLLOWING PAGES FILING THIS APPLICATION DOES NOT STAY THE COLLECTION OF YOUR SURCHARGE. TO AVOID INTEREST AND COLLECTION CHARGES, YOU MUST PAY SURCHARGE AS BILLED BY DUE DATE. IF EXEMPTION IS GRANTED AND SURCHARGE IS PAID IN FULL, REFUND WILL BE MADE. THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE Return To: Board of Assessors 93 Washington Street - Room 6 Salem, MA 01970 Must be filed on or before the deadline of April 1, 2026 SIGN ---PAGE BREAK--- C. HOUSEHOLD MEMBERS. List all members of your household on January 1 and provide requested information. Please list any members who are 18 and older and not full time students last. Documentation may be requested to verify information provided. Full Name (First, Middle, Last) Relationship to Applicant Age as of 1/1 Occupation or School Grade 1. 2. 3. 4. 5. 6. Continue list on attachment, in same format, as necessary. D. HOUSEHOLD OUT OF POCKET MEDICAL EXPENSES DURING PRECEDING CALENDAR YEAR. List total medical expenses incurred by all household members during calendar year before January 1 that were not paid by or reimbursed by employer, public or private health insurance or other third party. Includes amounts paid in health insurance premiums, co-payments, deductibles and other out of pocket expenses. Documentation may be requested to verify expenses claimed. TYPE OF EXPENSE Total Out of Pocket for Preceding Calendar Year Health insurance premiums $ Doctors $ Hospitals $ Diagnostic tests $ Prescription drugs $ Medical equipment $ Other $ TOTAL OUT OF POCKET $ ---PAGE BREAK--- E. HOUSEHOLD GROSS INCOME DURING PRECEDING CALENDAR YEAR. List income received from all sources for each member of household 18 and older and not full time student during calendar year before January 1. Please list members in same order as shown in Schedule C above. Copies of federal and state income tax returns are required to verify income reported for each qualifying household member. TYPE OF INCOME Applicant Name Member 1 Name Member 2 Name Member 3 Name Wages, salaries, other compensation $ $ $ $ Social Security Other pension/retirement benefits Interest/dividends Rental income Net profits from business or profession Capital gains Alimony Child support Public assistance Unemployment compensation Disability compensation Other (specify): TOTAL GROSS INCOME - MEMBERS $ $ $ $ TOTAL GROSS INCOME - HOUSEHOLD $ Continue list on attachment, in same format, as necessary. F. CO-OWNERS’ HOUSEHOLD GROSS INCOME DURING PRECEDING CALENDAR YEAR. Does Schedule E above include the gross income of all co-owners of the property as of January 1, If no, a Schedule C, D and E must be attached for each co-owner not included. 2025 ? Yes No ---PAGE BREAK--- CITY OF SALEM Low/Moderate Income CPA Exemption FY26 Exemption Eligibility Requirements 1. Applicant must own the property as of January 1, 2025. May be sole owner, co- owner, life tenant or trustee with sufficient beneficial interest in property under terms of trust. 2. Applicant must occupy the property as primary residence as of January 1, 2025. 3. Applicant and each co-owner must have household income for the calendar year before January 1, 2025 at or below the limit for that owner’s household type and number (see chart below for specific formula by household type). For property subject to trust, each co-trustee must meet income standard. Calculation of Each Owner’s Household Income 1. Household annual gross income from all sources. Includes wages, salaries and bonuses, public and private pensions, retirement income, Social Security, alimony, child support, interest and dividend income, net income from business, public assistance, disability and unemployment insurance, regular contributions/gifts from party outside of the household. 2. Deduct Dependents Allowance. Number of dependents on January 1, 2025 (not spouse) x $ 300. (Established by the State Department of Housing and Community Development, 760 Code of Massachusetts Regulation 6.05(4). Currently $300 deduction per dependent.) 3. Deduct Medical Expenses Exclusion. Total out of pocket medical expenses of all household members for calendar year preceding January 1, 2025 (total must exceed 3% of household annual gross in order to be deducted). Out of pocket medical expenses include health insurance premiums, payments to doctors, hospitals and other health care providers, diagnostic tests, prescription drugs, medical equipment or other expenses not paid or reimbursed by employers, public/private insurers or other third parties. 4. Equals Household Annual Income for CPA Exemption Cannot exceed Annual Income Limit for Household Type and Size (see below) The Annual Income Limit is based on the Area Wide Medium Income (AWMI) set by the U.S. Department of Housing and Urban Development (HUD). released-cpa-limits-posted Household Size of persons) Senior Household (60yo+) (Moderate Income) Non-senior Household (Low Income) 1 person 112,630 90,104 2 person 128,720 102,976 3 person 144,810 115,848 4 person 160,900 128,720 5 person 173,772 139,018 6 person 186,644 149,315 7 person 199,516 159,613 8 person 212,388 169,910