Form 401 - Separate Assessment Application For Severed Mineral Interests
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TO BE FILED
FORM
WITH THE COUNTY
Separate Assessment Application
ASSESSOR
401
ON OR BEFORE
for Severed Mineral Interests
JANUARY 1
NAME AND ADDRESS OF OWNER OF SURFACE ESTATE
NAME AND ADDRESS OF OWNER OF MINERAL INTERESTS
Name
Name
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
County Name
Legal Description of Surface Estate
I request that the mineral interests severed from the surface estate described in this application be placed upon the
assessment and tax roll as property separate and distinct from the surface estate.
sign
Signature of Owner of Surface Estate
Date
or
here
Signature of Owner of Mineral Interests
Date
FOR COUNTY ASSESSOR’S USE ONLY
APPROVED
COMMENTS:
DISAPPROVED
Signature of County Assessor
Date
ATTACH ATTORNEY'S OPINION OR CERTIFICATE PREPARED BY A LICENSED ABSTRACTOR.
INSTRUCTIONS
WHO MAY FILE. Any person, corporation, or organization who is the owner of either the surface estate or mineral interest
may file a Separate Assessment Application for Severed Mineral Interests, Form 401, to apply for separate assessments. If
this form is not filed, the value of the mineral interest will continue to be assessed to the owner of the surface estate.
WHEN AND WHERE TO FILE. This Form 401 must be filed with the county assessor on or before January 1 of the year in
which the mineral interests are to be listed and assessed separately. All granted separate assessment applications will remain
in effect until notification to cease the separate assessment is received by the county assessor. The Form 401 does not need
to be filed annually.
APPEAL PROCEDURES. If this form is denied by the county assessor, the applicant may appeal to the county board of
equalization on or before June 30.
SIGNATURE. Either the owner of the surface estate or the owner of the mineral interest may complete and sign this form.
REQUIRED ATTACHMENT. The opinion of an attorney or certificate prepared by a licensed abstracter showing proof of
ownership of a severed mineral interest and a record of creation of the severed mineral interest must be attached.
Nebraska Department of Revenue, Property Assessment Division
Authorized by Neb. Rev. Stat. §§ 57-236 and 57-239
96-217-2001 Rev. 6-2012
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