Form Pv-Ad-1 - Annual Claim For Exemption From Property Taxation Page 3
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3EXEMPT REAL PROPERTY FORM
Supplemental page
If more than one building exists on a parcel identification number (PIN), please report only
one building on each copy of the Exempt Real Property Form. The requested information is
parcel specific. Make as many copies of this form as is necessary to report your exempt real
property.
Firm Name
Parcel Id.
: __________________________________
#: ________________________________________
Docket Number:
Exempt Period:
______________________________
____________________________________
Legal Description
:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________
Is land acquisition associated with this exemption?
Yes ____No ____
If land acquisition is associated with this exemption, then provide the following information:
What date was the land purchased?
_____________________________________________
What was the purchase price of the land?
________________________________________
If this is an Industrial Revenue Bond (IRBX) exemption, provide the amount of bond
•
funds spent on this parcel of land associated with this docket number:
___________________
If an improvement(s) is/are associated with this exemption, then provide the following information
:
Building name and number (if applicable):
________________________________________
Description of the improvement
: __________________________________________________________
__________________________________________________________________________________________
ate of completion:
D
______________________________________________________________________
Total square footage of the improvement:
_________________________________________________
Provide the total cost of the improvement attributable to the exemption under this docket
number
:_________________________________________________________________________________
If this is an Industrial Revenue Bond (IRBX) exemption, provide the amount of bond
•
funds spent on the improvement associated with this docket number:
____________________
If an in-lieu-of payment agreement is associated with this exemption provide the following
information:
Amount of in-lieu-of tax payment for _____ for this parcel: _____
____________________________
Please attach a copy of the in-lieu-of tax agreement.
I do hereby assert that the information furnished by me herein and in the attached schedules
is true, accurate, and complete.
Applicant's Signature _____________________________
Date:
_____________________
Name & Title
_____________________________
Phone: _____________________
Supplemental Form (Revised 6/2014)
ExemptRP.doc
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