CR-NBH
For Office Use Only
Approved
Name of organization _____________________________Assessment year ____________
Denied
Assessor’s signature ______________________________Date _______________________
Application for Property Tax Exemption for Nursing Homes and
Boarding Care Homes
Please read the instructions before you complete this form. Return to your county assessor by February 1.
To be completed by all applicants
Representative or Owner Last Name
First Name
Middle Initial
Title
Name of Organization
Mailing Address
City
State
Zip code
County
Parcel ID or legal description of property (from tax statement or valuation notice)
Certifications
I certify that the above organization is exempt from federal income tax under section 501(c)(3).
Yes
No
You must be able to certify one of the following as being true in order to qualify for the exemption:
I certify that this facility is certified to participate in the medical assistance program under
title 19 of the Social Security Act.
Yes
No
I certify that this facility does not discharge residents due to inability to pay.
Yes
No
Signature of Owner or Authorized Representative
By signing below, I certify that the above information is true and correct to the best of my knowledge, and I am the owner of the prop-
erty or authorized representative of the organization that owns the property for which exemption is being claimed.
Signature of Owner
Phone
Date
Include with this application a designation from the IRS proving status as a 501(c)(3) organization. Also include with this application
a copy of the facility’s discharge policy or proof that the facility is certified to participate in the medical assistance program under
title 19 of the Social Security Act.
(Rev. 11/13)