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2. AFFIDAVIT

   This affidavit is to be used by organizations seeking property tax exemption pursuant to Section 170 of the Kentucky Constitution. Answer all questions as fully as possible.

4. This affidavit is to become an integral part of the Application for Exemption from Property Taxation currently on file with the Kenton PVA office and to be used only for those entities seeking exemption on additional property(ies) originally not included and approved as part of the entity’s application for exemption.
6. Entity Name*
   Enter Exact Legal Name of Organization
7. Email Address
9. Property Location*
   Number and Street
11. City*
    -- Select One --BromleyCovingtonCrescent Springs Crestview Hills EdgewoodElsmereErlangerFairviewFt. Mitchell Ft. Wright IndependenceKenton ValeLakeside Park LudlowPark HillsRyland Heights Taylor Mill UnincorporatedVilla Hills Walton
12. State*
    -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPR
13. Zip Code*
15. Phone Number
16. Fax Number
18. Parcel IDentification Number (PIDN) if known
    as it is printed on your tax bill (e.g. 001-01-23-456.78)
20. Purpose of the Organization and Major Activity of Applicant
22. Describe the current use of the property above.
    Indicate whether any rents or income is received for this property and if so, the amount(s).
24. Petitioner's Agreement to Authorization of Inspection and Affidavit of Authority:*

    For this property tax exemption application, I authorize the Department of Revenue (DOR) or its representative(s) to visit and inspect the property to be exempted now and in the future, to ensure the property is being used for tax exempt purposes. I hereby certify that the statements and information contained herein are correct to the best of my knowledge and belief and that I am authorized to sign this application. All other information submitted as part of the original application that would impact the PVA’s or Department of Revenue’s decision in granting exemption remain the same.

    1. I Agree
28. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
30. Electronic Signature*
    Applicant Authorization and Signature
31. Signed Date*
    Signed Date
33. Title of applicant
37. Electronic Signature

    Property Valuation Administrator / Deputy

38. Date
    Date
39. Application is:
    -- Select One --ApprovedDenied
40. Verification
42. Data entry
43. Sentry file
44. Notification
45. Exoneration
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field