BELLINGHAM SENIOR CENTER & OFFICE OF THE COUNCIL ON AGING
508-966-0398
Date of application ________________________
CONFIDENTIAL APPLICATION FOR PROPERTY TAX WORK OFF PROGRAM
Name of applicant _____________________________________________________________
Address ______________________________________________________________________
Telephone number ________________________Cell_____________________ Birth date ____________
E-mail __________________________________________________
ELIGIBILITY REQUIREMENTS
60 years old by July 1 this year? Yes _____ No _____
Homeowner or current spouse of homeowner?* Yes _____ No _____
Bellingham resident? Yes _____ No _____
Reside in property for which relief is requested? Yes _____ No _____
*If property is in a trust, etc., please explain __________________________________________
EMERGENCY CONTACT INFORMATION
Name of emergency contact person: _____________________-------_______ Relationship: _____________
Address if not the same as yours: ________________________________________________________
Home Phone: ___________________________ Work Phone ____________________________
PLACEMENT INFORMATION
What are your past experiences, types of skills, and qualifications? _____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What date are you available to start work? ______________________________________________
Job placements may be available in a variety of Town departments. Indicate in which departments you would prefer to work, if possible.
_____ No Preference – Any
_____ Town Hall Offices
_____ Senior Center
_____ Schools
_____ Police
_____ Parks
_____ Library _____ Fire/EMT
_____ Dept. of Public Works
_____ Other- please explain: _______________________________________________________
Do you have any restrictions or needs which may affect any position—i.e., physical requirements, seasonal, schedule, hours of day (duration and/or number of hours), frequency, etc. Please explain.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please note:
- The Council on Aging is mandated by state law to do a CORI (criminal background check) on any person who works with seniors.
- Candidates placed with the School Department must be willing to sign a Criminal Offender Record Information (CORI) release form.
______________________________________________________________________________
As a participant in the Property Tax Work-Off Program, I understand that I may earn a maximum of $750 credit to be applied to my Town of Bellingham property tax bill in the following year. I further understand that this reduction in my property taxes may affect my eligibility for the state Circuit Breaker Credit.
Signature ________________________________ Date ______________
Please return this application to the Bellingham Senior Center 40 Blackstone Street, Bellingham 02019
FOR OFFICE USE ONLY
Referral to: _______________________________________________ Date _______________
____________________________________________ Date _______________
Disposition: __________________________________________________________________
If position declined, indicate reason: _______________________________________________
Interviewed by: ________________________________________________________________
PTWOapplformrevised10: 4/15/09
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