Full Text
THIS FORM MUST BE RETURNED TO OUR OFFICE BY EXEMPT PROPERTY APPLICATION COUNTY DIGEST YEAR TITLE HOLDER’S NAME NAME ON DIGEST PROPERTY ADDRESS DATE ACQUIRED MARKET VALUE OWNERSHIP (lease, fee simple, etc.) A. MARK THE APPROPRIATE DESCRIPTIONS OF ALL IMPROVEMENTS ON/TO THE PARCEL OF LAND: (The Total Number of Buildings=____) ( )Unimproved Raw Land ( )Single Family Residence ( )Parsonage(Not Rented) ( )Gov’t Owned Buildings ( )Concession Stand ( ) Church/Temple ( )Non-Profit Public Hospital ( )Recreation Facilities ( )Shrine ( )Public Library ( )Offices ( )Church Admin ( )Public (owned) Schools ( )Meeting Halls ( )Perp. Care Cemetery Off. ( )Private School-Open to ( )Club House ( )Paved Public ( )Housing Owned by ( ) Dormitories ( )OTHERS: (Specify) Fraternity Chapeters ( )Non-Profit Home for Aged ( )Classrooms ( )Pollution Control or Energy Saving (solar) Equipment (D.N.R. No. and include copy of certification). IN THE SPACE NEXT TO THE APPOPRIATE DESCRIPTION OF THE USE OF THE PROPERTY FOR WHICH THE EXEMPTION BEING APPLIED INDICATE THE PROPER PERCENTAGE WHICH EACH DESCRIPTION REPRESENTS TO THE TOTAL PROPERTY. (EXAMPLE: 10% Rel Burial. 20% Rel. Worship, 5% Parking, 65% Undeveloped Land). Land for Recreation Lot Place of Religious Worship Building Site of Religious Burial Owned for Investment OTHER: (specify) ---PAGE BREAK--- MARK ONE RESPONSE TO THE RIGHT OF EACH QUESTION BELOW. (N/A IS FOR THOSE QUESTIONS THAT DO NOT APPLY.) YES NO N/A 1) Are any of the improvements which have been designated in Section A or B of this form AT ANY TIME rented, leased, income or fees received for the use of any part of this property? (If yes is indicated, please identify and explain circumstances and terms on an attached sheet of paper.) 2) Is the property Open to the General Public? 3) Is the use of the property restricted, limited, subject to approval or reserved for the use by any person(s), group(s), or organization? 4) Does any person, group or organization have priority of use of property which is open the general public? 5) Is the premise used for private, social, or fraternal meetings? 6) Are the property uses controlled by any individual or organization other than owner of record? 7) Is the property owner exempt from Federal/State Income Tax? If yes, fill in the IRC Section No I.R.C. (example Section 501 8) If the corporation entity holds IRC 501 exemption, was it obtained prior To July 1, 1959? 9) Has the Federal or State Income Tax Exemption status ever been revoked or suspended? 10) Is the property owner a political subdivision or instrumentality of the County, State or Federal Gov’t? 11) Is the property within the territorial limits of the political Subdivision? 12) Is the Property owned by Private individuals? 13) Is the Property owned by Private organizations or clubs? 14) Is the Property owner a non-profit corporation without stockholders? PLEASE ATTACH SEPARATE SHEET IF NECESSARY, FOR RESPONSES TO THE QUESTION BELOW 15) Does the owner, any stockholder or officer receive any income or profit for services rendered of from the use of the property. If yes, explain on a separate sheet if necessary. 16) Is any incidental income received from non-rent use of the property? If so, please explain source and how the income is used on a separate attached sheet. ---PAGE BREAK--- 17) If services are rendered by the owner (hospital, charity home or aged, etc.) YES NO N/A are these services available to the public without regard to the ability to pay by the person requesting the services? (If no, explain circumstances on attached sheet). 18) Is there any reversionary benefit to anyone upon the sale of the property or changed in the use of property? (If yes, specify whom) 19) List sources of funds received along with an approximate percentage Breakdown for each source (example: contributions 50%; federal assistance 25%; public or patiens 20% dues or membership fee etc.) 20) Explain briefly, how these funds are used. 21) If the property of the property is vacant lot, do any activities occur on the premises? If yes, specify nature of activities and how often. 22) State briefly the specific grounds and purpose for filing for the exemption. I hereby certify the information attached and contained herein to be true and correct to the best of my knowledge and belief. Signature Date