1. Is the association exempt from federal income taxation under Section 501(a), Internal Revenue Code of 1986, as an
organization described by Section 501(c)(3)?
2. In the past year has the association loaned funds to, borrowed funds from, sold property to or bought property from a
shareholder, director or member of the association, or has a shareholder or member sold his interest in the association
for a prot?
If “YES,” attach a description of each transaction. For sales, give buyer, seller, price paid, value of the property sold
and date of sale. For loans, give lender, borrower, amount borrowed, interest rate and term of loan. Attach a copy of
note, if any.
3. Does the association provide assistance to ambulatory health care centers that provide medical care to individuals
without regard to the individuals’ ability to pay, including providing policy analysis, disseminating information, conducting
continuing education, providing research, collecting and analyzing data, or providing technical assistance to the health
care centers?
4. Is the association funded wholly or partly, or assists ambulatory health care centers that are funded wholly or partly, by
a grant under Section 330, Public Health Service Act (42 U.S.C. Section 254b), and its subsequent amendments?
Harris County Appraisal District
Exemption Center
13013 Northwest Fwy.
P. O. Box 922012
Houston, TX 77292-2012
(713) 957-7800
Form 11.183 (12/2019)
Application for Ambulatory Health Care Center
Assistance Exemption for ________
Year
GENERAL INSTRUCTIONS: This application is for use in claiming property tax exemptions pursuant to Tax Code §11.183. This application covers property you
owned on January 1 of this year or acquired during this year. You must furnish all information and documentation required by the application.
APPLICATION DEADLINES: You must le the completed application with all required documentation between January 1 and no later than April 30 of the year for
which you are requesting an exemption. If you acquired the property after January 1 of this year and wish to qualify for the exemption this year, you must apply
before the rst anniversary of the date you acquired the property, or before the rst anniversary of the date any property was acquired after January 1.
If the chief appraiser grants the exemption, you do not need to reapply annually, but you must reapply if the chief appraiser requires you to do so, or if you want
the exemption to apply to property not listed in this application. You must notify the chief appraiser in writing if and when your right to this exemption ends. Return
the completed form to the address above.
OTHER IMPORTANT INFORMATION
Pursuant to Tax Code §11.45, after considering this application and all relevant information, the chief appraiser may request additional information from you. You
must provide the additional information within 30 days of the request or the application is denied. For good cause shown, the chief appraiser may extend the deadline
for furnishing the additional information by written order for a single period not to exceed 15 days.
Name of Organization
Present Mailing Address (number and street)
City, State, ZIP Code Phone (area code and number)
Name of Person Preparing this Application Driver’s License, Personal I. D. Certicate, Title
or Social Security Number*
Yes No
Yes No
Yes No
Step 1. Provide Name and Mailing Address of Organization and Identity of Person Preparing Application
Step 2. Answer the Following Questions About the Organization
Continued on next page
If this application is for an exemption from ad valorem taxation of property owned by a charitable organization with a federal tax
identication number, that number may be provided here in lieu of a driver’s license number, personal identication certicate
number, or social security number:
* Unless the applicant is a charitable organization with a federal tax identication number, the applicant’s driver’s license number, personal identication certifcate number, or social
security account number is required. Pursuant to Tax Code Section 11.48(a), a driver’s license number, personal identication certicate number, or social security account number
provided in an application for an exemption led with a chief appraiser is condential and not open to public inspection. The information may not be disclosed to anyone other than an
employee of the appraisal ofce who appraises property, except as authorized by Tax Code Section 11.48(b). If the applicant is a charitable organization with a federal tax identication
number, the applicant may provide the organization’s federal tax identication number in lieu of a driver’s license number, personal identication certicate number, or social security
account number.
Yes No
Organization is a (check one): partnership corporation other (specify):
