Form Rp-412-A - Application For Real Property Tax Exemption Page 2
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RP-412-a (1/95)
c. Municipal corporations to which payments will
d. Person or entity responsible for payment
be made
Yes No
Name ____________________________
County _____________________
Title ____________________________
Town/City ___________________
Village ______________________
Address __________________________
School District ________________
________________________________
e. Is the IDA the owner of the property?
Yes
No (check one)
If “No” identify owner and explain IDA rights or interest
Telephone ________________________
in an attached statement.
6. Is the property receiving or has the property ever received any other exemption from real property taxation?
(check one)
Yes
No
If yes, list the statutory exemption reference and assessment roll year on which granted:
exemption ___________________________ assessment roll year ____________________________
7. A copy of this application, including all attachments, has been mailed or delivered on ___________ (date)
to the chief executive official of each municipality within which the project is located as indicated in Item 3.
CERTIFICATION
I, ___________________________________________ , _________________________________ of
Name
Title
_____________________________________________________ hereby certify that the information
Organization
on this application and accompanying papers constitutes a true statement of facts.
_______________________
___________________________________
Date
Signature
Clear Form
_____________________________________FOR USE BY ASSESSOR________________________________
1. Date application filed ___________________________________________
2. Applicable taxable status date ____________________________________
3a. Agreement (or extract) date _____________________________________
3b. Projected exemption expiration (year) _____________________________
4. Assessed valuation of parcel in first year of exemption $ _______________
5. Special assessments and special as valorem levies for which the parcel is liable:
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________
____________________________________
Date
Assessor’s signature
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