Fillable Application for Class 4c(3)(i) Non-Prot Community Service Organizations (Minnesota Department of Revenue)

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Application for Class 4c(3)(i) Non-Prot Community Service Organizations (Minnesota Department of Revenue)

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Type or Print
Application for Class 4c(3)(i) – Non-Prot Community Service
Organizations
(Rev. 5/13)
Provides for special classication of qualifying non-prot community service organizations
To qualify for the 4c(3)(i) classication, the law requires that the property is owned and used by a non-prot community service oriented
organization, is not used for residential purposes on either a temporary or permanent basis, and is not used for revenue-producing activities for
more than six days in the calendar year preceding the year of assessment.
Please read instructions before completing application.
4C3I
Certications
Name of Organization
Person Submitting Application Phone Number
Name Title
Address of Organization (cannot be a P.O. Box number)
City State Zip Code County
Property ID Number of Plat and Parcel Number (from tax statement)
Check the appropriate boxes.
I certify that this property is not used for residential purposes on either a temporary or permanent basis.
Yes No
I certify that the organization listed above is exempt from federal income taxation pursuant to section 501(c)(3), (8), (10), or (19) of
the Internal Revenue Code of 1986 as amended.
Yes No
I certify that the property or the portion of the property being enrolled for 4c(3)(i) classication was used for revenue producing
activities for six days or less in the calendar year preceding the year of assessment.
Yes No
Sign here
Signature of Applicant Title Date Daytime Phone
By signing below, I certify that the information on this form is true and correct to the best of my knowledge, and I am the
owner of the property or authorized representative of the organization that owns the property for which classication as
4c(3)(ii) is being claimed.
Signature of owner or authorized representative
Please return completed application and required attachments to your county assessor.
For Ofce Use Only
Approved
Denied
Name of applicant ________________________________Assessment year ____________
Assessor’s signature ______________________________Date _______________________
Who is Eligible
Property may qualify for class 4c(3)(i) and
the corresponding class rate if it is owned
by a “nonprot community service oriented
organization,” is not used for residential
purposes on either a temporary or perma-
nent basis, and:
• eorganizationisnotusedforrevenue-
producing activities for more than 6 days
in the calendar year preceding the year of
assessment.
A “nonprot community service oriented
organization” is any corporation, society,
association, foundation, or institution
organized and operated exclusively for
charitable, religious, fraternal, civic, or
educational purposes, and which is exempt
from federal income taxation pursuant to
section 501(c) (3), (8), (10), or (19) of the
Internal Revenue Code of 1986, as amended
through December 31, 1990.
Form Class 4c(3)(i) Application Instructions
Assessor May Request
Additional Information
ecountyassessormayrequest,atany
time, for an organization to provide a copy
of an IRS letter granting exempt status as a
501 (c)(3), (8), (10), or (19) corporation (or
an explanation of why the letter is not avail-
able), and other records that may be needed
to help the assessor determine an organiza-
tion’s eligibility.
How to Apply
Complete the entire application fully and
legibly. Mail the application and any re-
quired attachments to your county assessor.
Applications must be completed annually
and are for eligibility for the current year’s
assessment.
Use of Information
einformationonthisformisrequired
by Minnesota Statutes, section 273.13 to
properly identify you and determine if you
qualify for this property tax classication.
Your Social Security number is required. If
you do not provide the required informa-
tion, your application may be delayed or
denied. Your County Assessor may also ask
for additional verication of qualications.
Your Social Security number is considered
private data.
Penalties
Making false statements on this application
is against the law. Minnesota Statute 609.41
states that anyone giving false information
in order to avoid or reduce their tax obliga-
tions is subject to a ne of up to $3,000 and/
or up to one year in prison.
Information and Assistance
If you need additional information or as-
sistance, contact your county assessor.
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Application for Class 4c(3)(i) Non-Prot Community Service Organizations (Minnesota Department of Revenue)

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Completed 6 August 2020

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