Application For Property Tax Exemption Form - Randolph County Tax Department (Page 2 of 2) in pdf

3. Give the number of remaining lots or acres if any, and describe how all of this land is being used completely and exclusively for

purposes as stated in Section 1, Item # 3.

# of Lots _________________

__________________________________________________________________________

# of Acres _______________

__________________________________________________________________________

4. Please list buildings and land if any, which are not being completely and exclusively used for purposes as stated in Section 1,

Item # 3. ____________________________________________________________________________________________

____________________________________________________________________________________________________

5. Personal Property (Do not include registered motor vehicles - A separate application will need to be filed)

List personal property being used at the location _____________________________________________________________

____________________________________________________________________________________________________

6. Does any organization or individual other than the owner use this property: YES [ ] NO [ ] If YES, list the property being

used, the name of the user, the amount of time per month the property is used, and the income received per month for the

use of the property. __________________________________________________________________________________

__________________________________________________________________________________________________

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7. PLEASE READ AND COMPLETE THE AFFIRMATION

Under penalties prescribed by law, I hereby affirm that to the best of my knowledge and belief, all information in this application is

true and correct, and is made for the purpose of exempting the property herein described from property taxation as allowed under

North Carolina law.

__________________________

_______________________________________________________________________

Today’s Date

Signature of owner or authorized representative

Telephone: __________________________ Title ______________________________________________________________

Address:

_____________________________________________________________________________________________

==================================================================================================

OFFICE USE ONLY:

Account # _____________________________

Pin # ________________________________________________________

Statute G.S. 105- _______Approved by ____________Partially Approved____________________________________________

Rejected by ______Reason For_________________________________ ______________________Fiscal Year ____________

EXAPPL – revised 9/03

Application For Property Tax Exemption Form - Randolph County Tax Department Page 2