Form 50-171 - Request For Separate Taxation Of An Undivided Interest Page 2

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P r o p e r t y T a x

R e q u e s t f o r S e p a r a t e T a x a t i o n o f a n U n d i v i d e d I n t e r e s t

Form 50-171

STEP 4: Continued

___________________________________________________________________________________________________

Owner’s Name

___________________________________________________________________________________________________

Present Mailing Address

___________________________________________________________________________________________________

City, State, ZIP Code

___________________________________________________________________________________________________

Owner’s Name

___________________________________________________________________________________________________

Present Mailing Address

___________________________________________________________________________________________________

City, State, ZIP Code

STEP 5: Sign the Form

I hereby affirm that I own an undivided interest in the herein-described property in the proportion stated in this request.

I hereby request that my undivided interest in the specified property be listed on the appraisal records of the appraisal office separately from any remaining

undivided interest.

I certify that the information given on this form is true and correct.

_____________________________________________________________________

___________________________

Signature of Property Owner or Agent

Date

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