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I certify that the above organization is exempt from federal income tax under section 501(c)(3). Yes No You must be able to certify one of the following as being true in order to qualify for the exemption: I certify that this facility is certified to participate in the medical assistance program under title 19 of the Social Security Act. Yes No I certify that this facility does not discharge residents due to inability to pay. Yes No Property Information Representative or Owner Last Name First Name Middle Initial Title Name of Organization Mailing Address City State Zip code County Parcel ID or legal description of property (from tax statement or valuation notice) CR-NBH Application for Property Tax Exemption for Nursing Homes and Boarding Care Homes (Rev. 7/21) Please read the instructions before you complete this form. Return to your county assessor by February 1. Certifications To be completed by all applicants Certifications Signature of Owner Phone Date Signature of Owner or Authorized Representative By signing below, I certify that the above information is true and correct to the best of my knowledge, and I am the owner of the prop- erty or authorized representative of the organization that owns the property for which exemption is being claimed. Sign Here Include with this application a designation from the IRS proving status as a 501(c)(3) organization. Also include with this application a copy of the facility’s discharge policy or proof that the facility is certified to participate in the medical assistance program under title 19 of the Social Security Act. For Office Use Only Approved Denied Name of organization_ Assessor’s ---PAGE BREAK--- Filing for Exemption Minnesota Statutes 272.02, subdivision 90 provides a property tax exemption to qualifying nursing homes and boarding care homes. The facility must be exempt from federal income taxation pursu- ant to section 501(c)(3) of the Internal Revenue Code, and must meet one of the following requirements: • The facility is certified to participate in the medical assistance program under title 19 of the Social Security Act; or • The facility certifies that it does not discharge residents due to the inabil- ity to pay. Applications are due February 1of the assessment year. This application must be re-filed every third year. No matter what year the taxpayer initially files for exemption, applications will again be due in 2022, 2025, 2028, etc. In cases of sickness, absence, disability or for other good cause, the assessor may extend the deadline for filing the statement of exemption for a period not to exceed 60 days. Required Documentation You must provide the following docu- mentation with this application: • A designation from the IRS proving status as a 501(c)(3) organization; and either • a copy of the facility’s discharge policy showing that residents are not discharged due to the inability to pay; or • proof that the facility is certified to participate in the medical assistance program under title 19 of the Social Security Act. No property will be exempt from taxa- tion under Minnesota Statute 272.02 if the taxpayer claiming the exemption knowingly violates any of the provisions of this section. Assessor May Request Additional Information Upon written request by the assessor, taxpayers must make available to the assessor all necessary books and records relating to the ownership or use of property which can help verify whether or not the property qualifies for exemp- tion. Sale or Purchase of Exempt Property Property which is exempt from prop- erty tax on January 2 and, due to sale or other reason, loses its exemption prior to July 1 of that year, will be placed on the current assessment rolls for that year. The valuation will be determined with respect to its value on January 2 of such year. The classification will be based on the use to which the property was put by the purchaser, or in the event the purchaser has not uti- lized the property by July 1, the intend- ed use of the property, as determined by the county assessor, based upon all relevant facts. Use of Information The information on this form is required by Minnesota Statutes, sec- tion 272.02 to properly identify you and determine if you qualify for this property tax exemption. If you do not provide the required information, your application may be delayed or denied. Your County Assessor may also ask for additional verification of qualifications. Penalties Making false statements on this ap- plication is against the law. Minnesota Statutes, section 609.41 states that any- one giving false information in order to avoid or reduce their tax obligations is subject to a fine of up to $3,000 and/or up to one year in prison. Questions? Contact your County Assessor’s Office for assistance. Form CR-NBH Instructions