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9/2024 LOUDOUN COUNTY LAND USE ASSESSMENT DECLARATION OF INELGIBLE LAND GOVERNMENT CENTER 1 Harrison St. SE 1ST Floor Leesburg, VA 20175-3102 Robert S. Wertz, Jr., Commissioner of the Revenue P O Box 8000, MSC 32, Leesburg, VA 20177-9804 Phone (703) 737-8557 Fax (703) 777-0263 [EMAIL REDACTED] LOUDOUN TECH CENTER 46000 Center Oak Plaza Sterling, VA 20166-6597 PROPERTY ADDRESS: PIN: NUMBER OF ACRES: CONTACT NAME: CONTACT PHONE NUMBER: CONTACT EMAIL ADDRESS: DESCRIPTION OF ELIGIBLE AND INELIGIBLE LAND The Code of Virginia §58.1-3236 requires in determining the total area of real estate actively devoted to agricultural, horticultural, forest or open space use eligible land), there shall be included the area under barns, sheds, silos, cribs, greenhouses, public recreation facilities and like structures, lakes, dams, ponds, streams, irrigation ditches and like facilities. Ineligible land, which is land excluded from Land Use Assessment and assessed at fair market value, includes the area under houses, yards, personal gardens, driveways/roadways to houses, swimming pools, unused fields and any structure not related to the qualifying use. If the total area of ineligible land is less than one acre, please attach a sketch including a description and the calculation utilized to arrive at the area of ineligibility. It is the property owner’s responsibility to report any change in use of a qualified property, including ineligible land, to the local assessing official within sixty (60) days of such change. New Construction Permit Purpose: house, garage, barn, shed, garden, driveway, pool, unused fields, etc.) Does this construction directly support the property’s qualified use? If YES, please explain how. Provide estimated area/acres of land impacted by this construction AFFIDAVIT AND SIGNATURES I/We hereby certify that this declaration of ineligible land is accurate and represents the total area not used for a qualifying use. I/We also certify that I/we understand a material misstatement of fact will result in the assessment of roll back taxes and penalties allowed by law. I/We understand that this declaration will result in roll-back taxes on the area declared ineligible. Owner/Officer Signature & Date: Owner/Officer Signature & Date: Owner/Officer Signature & Date: Owner/Officer Signature & Date: