Form Fp 161 - Exempt Property Use Report - 2012 (Page 2 of 3) in pdf

PART I – CONTINUED

3a. If yes, give details. Please refer to enclosed instructions, number 7. ____________________________

______________________________________________________________________________

3b. State the square footage of the space provided, the tenant’s name, the period of time the space

was used to secure rent or income, and the amount of rent. ___________________________________

_____________________________________________________________________________________

4. Since the previous reporting year, has the use of any building or grounds, or any portion thereof,

changed?

O Yes

O No

4a. If yes, give details. ________________________________________________________________

_____________________________________________________________________________________

5. Were any buildings or structures added, altered, or removed during the reporting year?

O Yes

O No

5a. If yes, give details. ________________________________________________________________

_____________________________________________________________________________________

PART II—ONLY CATEGORY II FILERS MUST COMPLETE

1. Identify the provision of the District of Columbia Official Code under which this property is receiving

an exemption or abatement:

_____________________________________________________________________________________

2. Describe the community benefits, as identified in this law, provided by the property during the

reporting year. If none were provided, describe the progress made toward providing these benefits.

_____________________________________________________________________________________

AFFIDAVIT—ALL FILERS MUST COMPLETE

Under penalties of law, I declare that I have examined this report, and the statements made herein are true and complete to the

best of my knowledge, information, and belief. By signing below, I certify on behalf of the owner that, during the period covered

by this report, the real property has been used for the purpose for which the exemption or abatement was granted, except as stated

herein.

Signature

_______________________________________

Print Name

_______________________________________

Title

_______________________________________

Daytime Phone No. _______________________________________

Date

_______________________________________

FP 161 (Rev. 6/12)

Form Fp 161 - Exempt Property Use Report - 2012 Page 2