Short Form Instructions

Identification of Applicant & Property

Please provide your name, social security number and date of birth. Your spouse should be identified in section 3, even if he or she also qualifies.

  • Identify the property address and its schedule or parcel number.
  • List the city or town, property zip code and the telephone number where you may be reached.
  • List your mailing address here if different from your property address. If your mailing address is not located in the same community, please attach an explanation.

Note: Property can be held in a life estate.

Age, Occupancy & Ownership Requirements

To use the short form, all three questions in this section must be answered "True." If any questions are "False," please review the long form qualifications to see if you still qualify.

  • As of January 1 of this year. I am at least 65 years old.
  • The owner of record for the property described above is either a. me b. my spouse c. both of us. The property has been owned by one or both of us for at least 10 consecutive years prior to January 1 of this year. During periods when the property was owned by my spouse and not by me. my spouse and I were married, and my spouse occupied the property as his or her primary residence.
  • I occupy the property described above as my primary residence, and I have done so for at least 10 consecutive years prior to January 1 of this year.  

Each additional person who occupies the property as his or her primary residence must be listed here, along with his or her social security number. The form will be kept confidential. If your husband or wife occupies the property, he or she must be listed on the first line and identified as your spouse. If more than three additional people occupy the property, you may attach an additional sheet with their names and social security numbers.

Affidavit & Signature

You must sign and date the form. If the form is signed on behalf of the applicant by a guardian, conservator or attorney-in-fact, that person must provide documentation of his or her authority in the form of a court order or power of attorney. If there is a contact person other than the applicant, please provide that person's name and telephone number.


If you have any questions, please contact the Assessor's Office.