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Form Rp-421-F - Application For Real Property Tax Exemption For Capital Improvements To Residential Property - 1995 Page 2

RP-421-f (1/95)

NYS Board of Real Property Services

Certification

I, _______________________________, hereby certify that the information on this application and

any accompanying papers constitute a true statement of fact.

____________________________________

____________________

Signature of Owner

Date

-----------------------------------FOR ASSESSOR’S USE-----------------------------

1. Date application filed: ____________________

2. Applicable taxable status date: ____________________

3. Action on application: __________Approved

__________Disapproved (Reason):

________________________________________________________________________

4. Assessed valuation of parcel including improvement: $_______________

5. Assessed valuation of parcel excluding improvement: $_______________

6. Assessed valuation of improvement eligible for exemption: $_______________*

(4. minus 5.)

*This figure is the “exemption base” and must be recalculated in any year in which there is a

change in level of assessment of 15 percent.

Percent Amount

Dollar Amount

City/Town

_____%

$___________

Village

_____%

$___________

School District

_____%

$___________

County

_____%

$___________

____________________________________

____________________

Assessor’s signature

Date

Form Rp-421-F - Application For Real Property Tax Exemption For Capital Improvements To Residential Property - 1995 Page 2