Form 150-310-108 - Application For Exemption Of A Farm Labor Camp And/or Care Center

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APPLICATION FOR EXEMPTION
FOR OFFICIAL USE ONLY
OF A FARM LABOR CAMP
Date Received
AND/OR DAY CARE CENTER
Received By
Approved
ORS 307.495
Denied
(attach reason)
Note for Employment Department: Only send to CCD if
there is a Day Care Center.
INSTRUCTIONS
FOR ASSESSOR’S USE ONLY
• Your application must be filed with the county assessor on or before April 1.
Date Received
Received By
• File copies 1 through 5 with the county assessor.
Approved
Denied
• Keep copy 6 for your records.
Briefly explain reason for denial.
• Type or print neatly. Press firmly for legibility on all copies.
• If you are granted this property tax exemption, any in lieu of tax based upon
rentals must be paid to the county treasurer on or before November 15 (see
ORS 307.490). Failure to pay this in lieu of tax will cause the property tax
exemption to be denied in future years. (ORS 397.495)
Filed with the ________________________________________ County Assessor for the assessments beginning July 1, 20_____.
Name
Telephone Number
(
)
Address
City
State
ZIP Code
PROPERTY DESCRIPTION
Assessor’s Account Number(s) (as shown on your tax notice(s))
Map and Tax Lot No.
Personal Property (please describe)
APPLICATION FOR EXEMPTION
I hereby make application under the provisions of ORS 307.495 for the exemption of the property described above as a:
Day Care Center (complete Section A below)
Farm Labor Camp (complete Section B below)
I affirm that:
The facilities are owned and operated by a nonprofit corporation as a nonprofit facility.
The facilities are provided for the families of employees (or prospective employees of another person) and the employees (or
prospective employees are or will be engaged in agricultural work.
To the best of my knowledge, the facilities are in compliance with the requirements of the State Fire Marshal.
SECTION A —DAY CARE CENTER
This facility is a Day Care Center certified under ORS 657A.030 and 657A.250 to 657A.450.
The Day Care Center is operated in conjunction with or in cooperation with the following Farm Labor Camp:
Name: ________________________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________
SECTION B—FARM LABOR CAMP
This facility complies with the health code for Farm labor Camps adopted under the Oregon Safe Employment Act.
Describe the type(s) if agricultural work the employees will be engaged in or connected with: ____________________________________
______________________________________________________________________________________________________________________
DECLARATION
I declare under the penalties of false swearing [ORS 305.990(4)] that I have examined this document, and to the best of my knowledge
it is true, correct, and complete.
Name of Officer Making Application
Title
Signature
Date
X
150-310-108 (Rev. 2-00)
See other side for applicable law

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