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Form Ptax-300 - Application For Non-Homestead Property Tax Exemption - County Board Of Review Statement Of Facts Page 6

AFFIDAVIT FOR TAX EXEMPT USE

, being duly sworn under oath, understand that the

penalty of perjury can be imposed for falsified statements, and do hereby testify as follows:

1) I am the

_____________________________________________________________

(Title)

for _________________________________________________________________.

(Organization)

2) The real property(ies) identified as Permanent Index Number(s)

_______________________________

______________________________

_______________________________

______________________________

is/are being used solely by the

_____________________________________________________________________

(Organization)

for tax exempt purposes.

3) That the activity/usage of the property(ies) is as follows: ______________________

________________________________________________________________________

(attach additional page if needed)

Signed: ________________________________________

Subscribed and sworn to before me

this

day of

20 .

_______________________________________________

Notary Public

American LegalNet, Inc.

Form Ptax-300 - Application For Non-Homestead Property Tax Exemption - County Board Of Review Statement Of Facts Page 6