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This application and 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.
Enter Exact Legal Name of Organization
Number and Street
as it is printed on your tax bill (e.g. 001-01-23-456.78)
any rents or
income is received
for this property
and if so, the
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.
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.
Applicant Authorization and Signature
This field is not part of the form submission.
* indicates a required field