Application for Property Tax Exemption
                                                                                           
This application must be fi led with the assessor every year by February 1 of the year for which the exemption is claimed.

  Property Number:                                                                                                       Legal Description
  Property Owner:
  Property Address:
                               
Date property was acquired: _________________                                              Market value of property claimed exempt: $____________________

  Exemption Claimed Pursuant to One of the Following Sections of the North Dakota Century Code:
❒  1.  N.D.C.C. § 57-02-08(9), property used exclusively for public worship or property belonging to a religious organization and used 
            for religious purposes:     Church  ❒        Parsonage                         ❒                   Other (attach explanation)      ❒
❒  2.  N.D.C.C. § 57-02-08(8), property owned by an institution of public charity and used for the charitable purposes for which it was
            organized:        Public Hospital ❒ (1)      Nursing Home                      ❒ (1)               Other (attach explanation)      ❒ (1)
❒  3.  N.D.C.C. § 57-02-08(11), property owned by nonprofi t lodges, clubs, etc. and used for their meetings and ceremonies:
            a.  If licensed to sell alcoholic beverages, describe each area of the building where these beverages are sold or consumed.
            ________________________________________________________________________________________________________
            b.  If food is sold, describe each area of the building where the food is sold or consumed.
            ________________________________________________________________________________________________________
❒  4.  N.D.C.C. § 57-02-08(20), buildings owned and occupied as a homestead by one of the following:
            a.  Paraplegic Disabled Veteran or Veteran awarded specially adapted housing or unremarried surviving spouse                       ❒ (2)(4)(5)(6)
  b.  Permanently and Totally Disabled Person Confi ned to a Wheelchair or unremarried surviving spouse                   ❒ (2)
❒  5.  N.D.C.C. § 57-02-08(22), buildings owned by a blind person and/or spouse and occupied as a home by the blind person. (2)
❒  6.  N.D.C.C. § 57-02-08(26), buildings owned and occupied as a homestead by a paraplegic disabled person or unremarried surviving
            spouse. (2)(3)
❒  7.  N.D.C.C. § 57-02-08(31), group homes owned by nonprofi t corporations.
❒  8.  N.D.C.C. § 57-55-10, mobile home is exempt or the provisions of N.D.C.C. ch. 57-55 apply.
❒  9.  N.D.C.C. § ________________       Subsection ______________
For what purpose(s) was the property used during the 12-month period prior to the year for which this exemption is claimed? (Note: Be 
specifi c. If there were several types of use, indicate such usages by square foot areas of the building and fl oor location.  If additional space is 
needed, attach another sheet.)
__________________________________________________________________________________________________________________
Is any income derived from the use of any portion of this property by other individuals or groups, whether considered as rent or reimbursement
for expenses or services rendered?  Yes ❒           No ❒                                  If Yes, give details.
__________________________________________________________________________________________________________________
(1)  Provide a current copy of organizational documents supporting claim (e.g., articles of incorporation and by-laws, etc.) if claiming exemption for fi rst time or upon request.
(2)  Provide an affi davit or physician’s certifi cate if claiming exemption for fi rst time.
(3)  Provide an annual statement that previous year’s income did not exceed the amount provided in N.D.C.C. § 57-02-08.1.
(4)  Provide a copy of the DD Form 214 showing veteran’s honorable discharge from active military service if claiming exemption for fi rst time.
(5)  Provide evidence from the Department of Veterans Affairs showing award of specially adapted housing if claiming exemption for this status for fi rst time.
(6)  A person shall furnish to the assessor or other assessment offi cials when requested to do so any information that is believed will support the claim for exemption for a 
 subsequent year.
I (We) make application for real property tax exemption for the year ________ on the property described above and, in compliance with North 
Dakota Century Code § 57-02-14.1, certify the information is accurate to the best of my (our) knowledge and belief.
Note:  N.D.C.C. § 12.1-11-02 provides that making a false statement in a governmental matter is punishable as a Class A misdemeanor.

                                                                                           ______________________________________________________
                                                                                           Applicant                                                          Date
Application is:  Approved ❒         Disapproved ❒
                                                                                           ______________________________________________________
                                                                                           Assessor or Director of Tax Equalization                           Date
24740 (Rev. 3-12)