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LOUDOUN COUNTY LAND USE ASSESSMENT Request for Roll-back Tax Estimate GOVERNMENT CENTER 1 Harrison St. SE 1ST Floor Leesburg, VA 20175-3102 Robert S. Wertz, Jr., Commissioner of the Revenue P O Box 8000 Leesburg, VA 20177-9804 Phone (703) 737-8557 Fax (703) 777-0263 Email: [EMAIL REDACTED] LOUDOUN TECH CENTER 46000 Center Oak Plaza Sterling, VA 20166-8538 This request is for an estimate of roll-back taxes and not the current amount of taxes due. The resulting estimate is void 30 days from date of issuance. Future tax payments should NOT be based on this estimate. To initiate the imposition of roll- back taxes, please complete the Request for Roll-Back Taxes Invoice Form located on our website at loudoun.gov/landuse. The Code of Virginia §58.1-3237, requires real estate enrolled in the Land Use Assessment Program that changes to a non- qualifying use or that is zoned to a more intensive use at the request of the owner, be subject to additional taxes called roll- back taxes. The change must be reported to the Commissioner of the Revenue within 60 days of the change. Roll-back taxes are based on the difference between the use value assessment and the fair market value of the land for the current year as well as the previous five tax years. This difference is known as deferred value upon which the deferred tax is calculated and levied, along with simple interest. PARCEL OWNER(S) OF RECORD: MAILING ADDRESS OF REQUESTOR: PARCEL IDENTIFICATION NUMBER/PIN (One form per parcel): PARCEL ADDRESS (If different from mailing address): ACREAGE SUBJECT TO ROLL-BACK TAX: TELEPHONE NUMBER(S): EMAIL ADDRESS: REASON FOR ROLL-BACK Voluntary withdrawal of property from the Land Use Assessment Program Change to a non-qualifying use Date of Change: / / Rezoning to a more intensive use Date of Rezoning: / / CERTIFICATION I understand that I am requesting an estimate of roll-back taxes, not the amount of taxes due and is void after 30 days. I further understand that payment of roll-back taxes should not be submitted based on the estimate provided. Requestor’s Signature Date Requestor’s Printed Name Relationship to Property Owner Company Email Address Telephone Number Fax Number VER 08052024