Form Rp-421-F - Application For Real Property Tax Exemption For Capital Improvements To Residential Property Page 2

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RP-421-f (1/95)
2
Certification
I, _______________________________, hereby certify that the information on this application and
any accompanying papers constitute a true statement of fact.
____________________________________
____________________
Signature of Owner
Date
Clear Form
-----------------------------------FOR ASSESSOR’S USE-----------------------------
1. Date application filed: ____________________
2. Applicable taxable status date: ____________________
3. Action on application: __________Approved
__________Disapproved (Reason):
________________________________________________________________________
4. Assessed valuation of parcel including improvement: $_______________
5. Assessed valuation of parcel excluding improvement: $_______________
6. Assessed valuation of improvement eligible for exemption: $_______________*
(4. minus 5.)
*This figure is the “exemption base” and must be recalculated in any year in which there is a
change in level of assessment of 15 percent.
Percent Amount
Dollar Amount
City/Town
_____%
$___________
Village
_____%
$___________
School District
_____%
$___________
County
_____%
$___________
____________________________________
____________________
Assessor’s signature
Date

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