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Type or Print Application for Class 4c(3)(i) – Non-Profit Community Service Organizations (Rev. 11/13) Provides for special classification of qualifying non-profit community service organizations To qualify for the 4c(3)(i) classification, the law requires that the property is owned and used by a non-profit community service oriented organization, is not used for residential purposes on either a temporary or permanent basis, and is not used for revenue-producing activities for more than six days in the calendar year preceding the year of assessment. Please read instructions before completing application. CR-4C3I Certifications Name of Organization Person Submitting Application Phone Number Name Title Address of Organization (cannot be a P.O. Box number) City State Zip Code County Property ID Number of Plat and Parcel Number (from tax statement) Check the appropriate boxes. I certify that this property is not used for residential purposes on either a temporary or permanent basis. Yes No I certify that the organization listed above is exempt from federal income taxation pursuant to section 501(c)(3), (10), or (19) of the Internal Revenue Code of 1986 as amended. Yes No I certify that the property or the portion of the property being enrolled for 4c(3)(i) classification was used for revenue producing activities for six days or less in the calendar year preceding the year of assessment. Yes No Sign here Signature of Applicant Title Date Daytime Phone By signing below, I certify that the information on this form is true and correct to the best of my knowledge, and I am the owner of the property or authorized representative of the organization that owns the property for which classification as 4c(3)(ii) is being claimed. Signature of owner or authorized representative Please return completed application and required attachments to your county assessor. For Office Use Only Approved Denied Name of Assessor’s ---PAGE BREAK--- Who is Eligible Property may qualify for class 4c(3)(i) and the corresponding class rate if it is owned by a “nonprofit community service oriented organization,” is not used for residential purposes on either a temporary or perma- nent basis, and: • The organization is not used for revenue- producing activities for more than 6 days in the calendar year preceding the year of assessment. A “nonprofit community service oriented organization” is any corporation, society, association, foundation, or institution organized and operated exclusively for charitable, religious, fraternal, civic, or educational purposes, and which is exempt from federal income taxation pursuant to section 501(c) (10), or (19) of the Internal Revenue Code of 1986, as amended through December 31, 1990. Form CR-4C3I Instructions Assessor May Request Additional Information The county assessor may request, at any time, for an organization to provide a copy of an IRS letter granting exempt status as a 501 (10), or (19) corporation (or an explanation of why the letter is not avail- able), and other records that may be needed to help the assessor determine an organiza- tion’s eligibility. How to Apply Complete the entire application fully and legibly. Mail the application and any re- quired attachments to your county assessor. Applications must be completed annually and are for eligibility for the current year’s assessment. Use of Information The information on this form is required by Minnesota Statutes, section 273.13 to properly identify you and determine if you qualify for this property tax classification. If you do not provide the required informa- tion, your application may be delayed or denied. Your County Assessor may also ask for additional verification of qualifications. Penalties Making false statements on this application is against the law. Minnesota Statute 609.41 states that anyone giving false information in order to avoid or reduce their tax obliga- tions is subject to a fine of up to $3,000 and/ or up to one year in prison. Information and Assistance Contact your County Assessor’s Office for assistance.