Tax-Exempt Status Request Form Page 3
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5REQUIRED INFORMATION (continued)
III. OTHER INFORMATION (continued)
3. Do the individuals whose activities are related to the exempt purpose ever use
3a. State who makes such use of rooms or areas.
rooms or areas for activities not directly related to the basis for the claimed
exemption? (If “No”, skip to 4.)
3b. State specifically what rooms or areas are so used.
3c. State specifically how often such rooms or areas are to be used.
4a. State the uses for which such fees are charged.
4. Are fees ever charged to those who make use of rooms or
areas? (If “No”, skip to 5.)
Yes
No
4b. State how often such fees are charged.
4c. State who is charged such fee.
4d. State what fee is charged.
4e. For what purpose is the revenue derived from such fee used?
5. How many individuals participate in the
exempt activities?
6a. State the activity.
6. Are any rooms or areas ever used by any income generating
activity? (If “No”, skip to 7.)
Yes
No
6b. State specifically where it occurs.
6c. State specifically how often it occurs.
6d. State who conducts such activity.
7. Are food or items of any sort ever sold?
7a. State what is sold.
(If “No”, skip to 8.)
Yes
No
7b. State specifically where it is sold.
7c. State specifically how often such sales occur.
7d. State specifically who makes such sales.
8a. State the activity.
8. Are dances, dinners or other social functions ever held on the property for which the
exemption is claimed? (If “No”, skip to 9.)
Yes
No
8b. State specifically where it occurs.
8c. State specifically how often it occurs.
8d. State who conducts such activity.
9a. If so, specifically describe such goods, crops or food.
9. Are goods, crops, or food of any sort ever made, grown, or
produced on the property?
Yes
No
9b. State specifically the number or amount of goods, crops or food made, grown or produced.
9c. State specifically where such goods, crops or food is made, grown or produced.
9e. State the dollar value of each good, crop or food made, grown or produced.
9d. State specifically who makes, grows, or produces such goods, crops or food.
Use this area if additional space is needed for answers or if you wish to provide additional information.
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