Application For Institutions Of Purely Public Charity Property Tax Exemption Page 2

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Do you provide your goods or services for reduced or no cost?
Yes
No
If yes, provide an example:
If any of the recipients pay market value for your services, explain:
Are any of the organization’s profits (including donations, gifts, or income) distributed to private interests?
Yes
No
Are the beneficiaries of the charity restricted to any group of persons?
Yes
No
If yes, explain the reason for restriction:
Upon dissolution, are dividends or assets made available to private interests?
Yes
No
Signature of Owner or Authorized Representative
By signing below, I certify that the above information is true and correct to the best of my knowledge, and I am the
owner of the property or authorized representative of the organization that owns the property for which exemption is
being claimed.
Signature of Owner
Phone
Date

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