Tax-Exempt Status Request Form Page 4
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5ACTION BY THE COUNTY PROPERTY TAX ASSESSMENT BOARD OF APPEALS
INSTRUCTIONS:
In order to grant an application for an exemption, in whole or in part, the County PTABOA must specifically find that the statutory
prerequisites for an exemption have been met. If any of the statutory conditions have not been met, the exemption CANNOT BE GRANTED.
If you need additional space to answer any questions or wish to provide additional information, please attach a separate sheet.
THE SECRETARY OF THE COUNTY PTABOA MUST ANSWER ALL QUESTIONS.
Name of taxpayer
EXEMPTION ALLOWED
EXEMPTION NOT ALLOWED
ASSESSED
DESCRIPTION
ASSESSED
ASSESSED
VALUE
PERCENT
PERCENT
VALUE
VALUE
Land and lots
$
$
$
1.
2.
3.
Improvements (Buildings)
$
$
$
1.
2.
3.
Personal property
$
$
$
1.
2.
3.
0.00
0.00
0.00
0.00
0.00
TOTALS
$
$
$
Date application filed (month, day, year)
Was the entire application completely filled out (pages 1, 2, and 3)?
Yes
No
Was any information not in writing or on the form presented to the County PTABOA? If yes, complete next line.
Yes
No
State who presented the information and summarize the information provided.
Did the County PTABOA consider the actual use of the property?
Yes
No
What is the percentage of actual exempt use of each room, area, or building for which the exemption is claimed?
What is the exempt use of the property?
State the specific statute under which the application was granted or denied:
COUNTY PTABOA
Signature of County Assessor (Secretary of PTABOA)
Date signed (month, day, year)
Printed name of County Assessor (Secretary of PTABOA)
Page 4 of 5
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