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G:\Tax Exemptions and Deferrals\Land Use\LU-Forms\Word Documents for PDF files\Request for Roll-back Tax Invoice 08052024.docx LOUDOUN COUNTY LAND USE ASSESSMENT Request for Roll-back Tax Invoice 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 form is used to request the liability for roll-back taxes due to a change in the land use of the parcel. Per the Code of Virginia §58.1-3237, a change to a non-qualifying use or zoning 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. PARCEL OWNER(S) OF RECORD: BILLING ADDRESS: PARCEL IDENTIFICATION NUMBER/PIN (One form per parcel): PARCEL ADDRESS (If different from billing 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: / / Rezoned to a more intensive use Date of Rezoning: / / CERTIFICATION I/We the undersigned property owner(s) or authorized agent hereby certify that the property above no longer qualifies for land use assessment and request roll-back taxes be assessed according to the Code of Virginia §58.1-3237 and Chapter 848 of the Codified Ordinances of Loudoun County. I/We understand that this request will trigger the levy of roll-back taxes plus interest that will be billed by the Loudoun County Treasurer. I/We also understand that roll-back taxes will be due 30 days from the creation of the invoice and that if not paid by the due date, will accrue penalty and interest on the amount of the roll-back taxes including the interest for prior years. Owner’s/Agent Signature Date Owners/Agent’s Printed Name Owner’s Signature Date Owner’s Printed Name Owner’s Signature Date Owner’s Printed Name Owner’s Signature Date Owner’s Printed Name VER08052024 CLEAR FORM