Rp Form 19-77 - Charitable & Miscellaneous Exemption - 2011
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1CASE NO.
)
RP Form 19-77 (Rev 02/2011
TAX MAP KEY/PARCEL ID
DEPT. OF FINANCE
COUNTY OF HAWAI‘I
ISLE
Z
S
PLAT
PARCEL
CPR
REAL PROPERTY TAX DIVISION
3
101 Pauahi St., Ste. No. 4, Hilo, Hawai‘i 96720
Phone: (808) 961-8201
74-5044 Ane Keohokalole Hwy., Bldg. D, 2nd Flr., Kailua-Kona, Hawai‘i 96740
Phone: (808) 323-4880
CLAIM FOR CHARITABLE AND MISCELLANEOUS EXEMPTION
Exemption is hereby claimed from Real Property under County Ordinance
Chapter 19 Section 19-77.
[
] SCHOOL
[
] CEMETERY
[
] HOSPITAL/NURSE HOME
[
] PUBLIC USE
[
] CHURCH
[
] NON-PROFIT
[
] OTHER SPECIFY: ___________________________________________
Name of Organization: ____________________________________________________________________________
Mailing Address _________________________________________________________________________________
________________________________
Telephone Number
1. Explain the charitable or miscellaneous use: ________________________________________________________
____________________________________________________________________________________________
2. Is all the land and/or buildings used exclusively for the purpose claimed? [
] Yes [
] No
3. If the answer is no, explain and state area used for business.
____________________________________________________________________________________________
____________________________________________________________________________________________
4. Submit documentation from the Internal Revenue Service verifying exemption status.
CERTIFICATION
I declare, under penalty of law, that all statements in this return are true and correct to the best of my knowledge. I
understand that any misstatement of facts will be grounds for disqualification and penalty.
Date ________________________ 20______
______________________________________________
__________________________________________
(Print Officer’s Name)
Officer’s Signature
-------------------------------------------------------------------------------------------------------------------------------------------------------------
(For Tax Office Use Only)
Effective ____________________ Tax Year
Date Received (U.S. Postmark):_______________________ 20____
By: __________________________________
Claim Disallowed for __________________ Tax Year
Input Date: _______________________
Input Date:________________________
By: ___________________________________
By: _______________________________________
Reason:__________________________________________
PITT______
EX CD ______
CARD # ______
BUILDING % ______
LAND % ______
Hawai‘i County is an Equal Opportunity Provider and Employer
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