Form 801a - Assessor Notification Property Claimed For 12 Or Fewer Years - 2012 Page 2
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1
2ASSESSOR NOTIFICATION
2012
2012
PROPERTY CLAIMED FOR 12 OR FEWER YEARS
Form 801A
(page 2)
A.
B.
C.*
D.
E.
F.
Property
State of Origin
Number
Date Placed in
Original
Assessed Value
Description
(if acquired
of Years
Service
Cost
(To be completed by
used)
Claimed
(month/year)
local tax assessor.)
16. __________________________
_______
______
__________
$ _____________
$ _____________
17. __________________________
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______________
18. __________________________
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19. __________________________
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20. __________________________
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21. __________________________
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22. __________________________
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23. __________________________
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24. __________________________
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25. __________________________
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26. __________________________
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27. __________________________
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28. __________________________
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29. __________________________
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30. __________________________
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31. __________________________
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32. __________________________
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33. __________________________
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34. __________________________
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35. __________________________
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36. __________________________
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______________
______________
(
Attach additional sheets if needed)
_____________
TOTALS
$ _______________
$
* Form 801A is for property claimed 12 or fewer years. See instructions.
SECTION 3. Property Tax Information (To be completed by local tax assessor.)
Property Tax Rate ___________________ Assessed Tax $ _____________________ For Taxes Assessed April 1, ___________
Assessor Signature _______________________________ Municipality Name _______________________ Date ___________
______________________________________
____________________________________
_________________
Applicant (or agent) Signature
Social Security Number or Federal EIN (see note, page 5)
Date
R
06/12
EVISED
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