RP-485-n (11/12) (back)
5. Use of property
a. Describe the primary use of the property and the type of business to be conducted _______________
__________________________________________________________________________________
b. Describe any other uses of the property __________________________________________________
c. Does any portion of the project in residential use include dwelling units in a hotel?
Yes
No
6. Other exemptions:
a. Is the property receiving, or has it ever received, any other exemption from real property taxation?
Yes
No
b. If Yes, what exemption was received? ___________________________ When? _______________
Were payments in lieu of taxes made during the term of that exemption? Yes
No
If Yes, attach a schedule showing the amounts and dates of such payments, and the purposes for
which such payments were made (i.e., school district, general municipal, etc.). Also attach any related
documentation, such as a copy of the agreement under which such payments were made.
Certification
I, ____________________________________, hereby certify that the information on this application and any
accompanying pages constitutes a true statement of facts.
_____________________________________________
______________________
Signature
Date
For Assessor’s Use
1. Date application filed: ____________
2. Applicable taxable status date: ________________
3. Action on application: Approved
Disapproved
4. Assessed valuation of parcel in first year of exemption: $ _______________________
5. Increase in total assessed valuation in first year of exemption: $ ______________________
6. Amount of exemption in first year:
Percent
Amount
County
__________________
$ __________________
City/Town
__________________
$ __________________
Village
__________________
$ __________________
School District
__________________
$ __________________
______________________________________________
_________________________
Assessor’s signature
Date
Clear Form