Form Pt-64 - Property Tax Statement Of Exemption For Property Used For Pollution Control

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PT-64
Property Tax Statement of Exemption
for Property Used for Pollution Control
Name of business which occupies or uses the property
Minnesota Tax ID number
Name(s) of property owner(s)
Mailing address
City
State
Zip code
Check box and fill in name of city or township where property is located
County
City
Township
Legal description of the real property as shown on tax records
Parcel ID
Purpose of your business
Equipment or devices for which the tax exemption is claimed
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
Name of equipment or device
Date of application
Date of order granting exemption
I declare the real and personal property listed above was constructed or installed after June 1, 1967 and is totally or
primarily used for the abatement and control of air, land or water pollution. I certify that the above information is true
and correct to the best of my knowledge. I understand that Minnesota Statutes, section 609.41, states that anyone giv-
ing false information in order to avoid or reduce their tax obligations is subject to a fine of up to $3,000 and/or up one
year in prison.
Signature
Title
Date
Name of Contact Person
Email Address
Phone
Mail to Minnesota Revenue, Mail Station 3340, St. Paul, MN 55146-3340
or send an electronic version to sa.property@state.mn.us
(2/13)

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