Application For Sliding Scale Market Value Exclusion - Minnesota Department Of Revenue
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1
2Application for Sliding Scale Market Value Exclusion
for Electric Power Generation Efficiency
Type of Application:
Original
Renewal
Name of business which occupies or uses the property
Minnesota Tax ID number
Date of application
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
Efficiency Determination
(See instructions - attach an additional sheet if necessary)
Inputs
Amounts
BTUs
1 Total inputs (add all Inputs row above) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Useful electrical power output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Useful thermal energy output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Useful fuel energy of chemical products . . . . . . . . . . . . . . . . . . . . . . . 4
5 Add lines 2, 3 and 4 . This is your total outputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Divide line 5 by line 1 . Enter result as a percentage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
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 giving 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 (please print)
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 .
(10/14)
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