BILLINGS COUNTY APPLICATION: ___________
TAX EQUALIZATION & ZONING OFFICE
PHONE: (701) 623.4810 ● FAX: (701) 623.4761
495 4
TH
STREET ● PO BOX 247 - MEDORA, ND 58645-0247
stswanson@nd.gov jhammerstrom@nd.gov
AFFIDAVIT
APPLICANT: Name: ____________________________________________________________________
Phone: ________________ Cell: _____________________ Email: ____________________
OWNER: Same as above Name:______________________________________________
LEGAL DESCRIPTION OF PROPERTY: Parcel Number: __________ - __________ - __________ - _____
Qtr/Qtr: ____________ Section: ____________ Township:_________________ Range: ___________________
Under Penalty of Perjury, I certify that the structure proposed falls under the North Dakota Century Code 54-21.3-04.
Deeming this structure is exempt.
The following exemptions include but are not limited to: (Please indicate which exemption you wish to claim)
Building which is neither heated nor cooled.
Buildings used peak design rate of energy usage is less than one watt per square foot [929.0304 square centimeters]
or three and four-tenths British thermal units are hour per square foot [929.0304 square centimeters] of floor area.
A restore or reconstructed building deliberately preserved beyond its normal term of use, because of the historical
associations, architectural interests, or public policy, or buildings otherwise qualified as a pioneer building, historical site,
state monument, or other similar designation pursuant to state and local law.
Any building used for agricultural purposes, unless a place of human habitation or for use by the public, is exempt
from this chapter.
___________________ __________________ _________________________ _________________________
STATE OF NORTH DAKOTA }
} ss
COUNTY OF BILLINGS }
On this _________ day of ____________________, in the year _____________, before me personally appeared
_________________________________________________, known to me to be the person described in and who
executed the within and foregoing instrument, and severally acknowledged to me that _________ executed the same.
(he/she)
(SEAL) __________________________________
Notary Public
State of North Dakota
