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UCA §59-2-1101 and 1102 Form PT-21 PT-021.ai Rev. 2/03 Annual Statement for Continued Property Tax Exemption This statement should be used annually to apply for continued exemption from property tax. General Information Name of organization applying (must be record owner of property) Address Current tax year City State Zip code Tax year of original exemption Contact person / authorized representative Telephone number Property location, including county Parcel, account or serial number Questions 1. Has there been any change in the use of this property since January 1 of last year? Yes No If yes, describe: 2. Does any person or organization conduct business for profit on the property listed above? Yes No If yes, describe the use and give the name and address of the property user: 3. Does any organization use the real property listed above and pay a fee greater than the cost of maintenance and utilities? Yes No If yes, describe the use and give the name and address of the property user: 4. Is any personal property at this location being leased or rented from someone else? Yes No If yes, list the name and address of the owner and the type, make, model and serial number of the property: Certification I certify that all the information hereon, including any accompanying statements or documents, is true, correct and complete to the best of my knowledge and belief. Signature of owner of record Position with organization Date or owner's authorized representative