Clear Form
OREGON FOOD PROCESSOR EXEMPTION CLAIM
DEPARTMENT OF REVENUE USE ONLY
Tax Year 2012-13
Postmark Date
[Oregon Revised Statute (ORS) 307.453 – 307.459]
INSTRUCTIONS
FOR ASSESSOR’S USE ONLY
• See page 2 of this form for further filing instructions.
Date Received
Received By
Filing Fee
• File with the Oregon Department of Revenue if it appraises your
$
property under ORS 306.126. If your property is appraised by the
Account Number
Code Area Number
Approved
county assessor, file with the assessor of the county containing the
Denied
property.
Briefly Give Reason for Denial
• File after January 1 and on or before March 1 directly following the year
in which the property is newly acquired and first placed into service.
• Attach the certification(s) listing all qualified machinery and equipment certified by the Oregon Department of Agriculture.
• This claim for exemption is filed in addition to filing your Industrial Property Return or Real Property Return on or before March 1,
under ORS 308.290.
• You may access this form on the Department of Revenue’s website at
FILER / TAXPAYER
Name of Food Processor
Telephone Number
County where business and property are located
(
)
Mailing Address
City
State
ZIP Code
Location of Property (street address if different from above)
City
State
ZIP Code
Map and Tax Lot Number of Site
Contact Person
Title
LATE FILING
Extensions for your Industrial or Real Property Return do not apply to this claim.
1.
Check to indicate that you are filing after March 1 and on or before December 31 in the year of exemption.
c
Check to indicate that you are including, with this claim, the required late filing fee.
2.
c
3. Check to indicate the method you used to calculate your late filing fee. You must choose the one method that equals the greater
amount.
$200, or
c
c
1
⁄
of 1 percent of the real market value (RMV) of your certified exempt real and personal property:
10
0.001 x ________________ (RMV) = ________________ (late filing fee)
To arrive at your RMV, add the invoice cost of the machinery and equipment, installation, engineering, and miscellaneous costs
including machinery process piping, foundations, power wiring, interest during installation, and freight.
EXEMPTION ON QUALIFIED PROPERTY
1. This property tax exemption is requested for the tax year beginning July 1, ____________ and ending June 30, ____________.
2. Certification(s) listing all qualified machinery and equipment is attached.
Check here if you’ve attached additional pages.
c
Certification number: ________________ Certification number: ________________ Certification number: ________________
Certification number: ________________ Certification number: ________________ Certification number: ________________
3.
Check to indicate that your business is responsible for payment of all ad valorem taxes assessed on all of the subject certified
c
property held by you under a lease or lease agreement.
DECLARATION*
I declare under penalties of false swearing [ORS 305.990(4)] that I have examined this document and attachments, and to the best of my
knowledge, they are true, correct, and complete. I have concluded that my business satisfies the requirements of a qualified business
and complies with all local, Oregon, and federal laws that are applicable to my business.
MUST BE SIGNED BY AN OWNER, COMPANY EXECUTIVE, OR AUTHORIZED REPRESENTATIVE OF THE BUSINESS*
Signature*
Date*
X
Title (if not an owner or executive, attach letter attesting to appropriate contractual authority)
THIS CLAIM DOES NOT REPLACE YOUR INDUSTRIAL OR REAL PROPERTY RETURN
150-303-085-1 (Rev. 09-11)
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