I certify that the above organization is exempt from federal income tax under section 501(c)(3). Yes No
You must be able to certify one of the following as being true in order to qualify for the exemption:
I certify that this facility is certied to participate in the medical assistance program under
title 19 of the Social Security Act.
Yes No
I certify that this facility does not discharge residents due to inability to pay.
Yes No
Property Information
Representative or Owner Last Name First Name Middle Initial
Title Name of Organization
Mailing Address
City State Zip code County
Parcel ID or legal description of property (from tax statement or valuation notice)
NBH
Application for Property Tax Exemption for Nursing Homes and
Boarding Care Homes
(Rev. 5/13)
Please read the instructions before you complete this form. Return to your county assessor by February 1.
Certications
To be completed by all applicants
Certications
Signature of Owner Phone Date
Signature of Owner or Authorized Representative
By signing below, I certify that the above information is true and correct to the best of my knowledge, and I am the owner of the prop-
erty or authorized representative of the organization that owns the property for which exemption is being claimed.
Sign Here
Include with this application a designation from the IRS proving status as a 501(c)(3) organization. Also include with this application
a copy of the facility’s discharge policy or proof that the facility is certied to participate in the medical assistance program under
title 19 of the Social Security Act.
For Ofce Use Only
Approved
Denied
Name of organization _____________________________Assessment year ____________
Assessor’s signature ______________________________Date _______________________
Filing for Exemption
Minnesota Statutes 272.02, subdivision
90 provides a property tax exemption to
qualifying nursing homes and boarding
care homes. e facility must be exempt
from federal income taxation pursu-
ant to section 501(c)(3) of the Internal
Revenue Code, and must meet one of
the following requirements:
• efacilityiscertiedtoparticipate
in the medical assistance program
under title 19 of the Social Security
Act; or
• efacilitycertiesthatitdoesnot
discharge residents due to the inabil-
ity to pay.
Applications are due February 1of the
assessment year. is application must
bere-ledeverythirdyear.Nomatter
whatyearthetaxpayerinitiallylesfor
exemption, applications will again be
due in 2013, 2016, 2019, etc.
In cases of sickness, absence, disability
or for other good cause, the assessor
mayextendthedeadlineforlingthe
statement of exemption for a period not
to exceed 60 days.
Required Documentation
You must provide the following docu-
mentation with this application:
• AdesignationfromtheIRSproving
status as a 501(c)(3) organization; and
either
• acopyofthefacility’sdischarge
policy showing that residents are not
discharged due to the inability to pay;
or
• proofthatthefacilityiscertiedto
participate in the medical assistance
program under title 19 of the Social
Security Act.
Nopropertywillbeexemptfromtaxa-
tion under Minnesota Statute 272.02
if the taxpayer claiming the exemption
knowingly violates any of the provisions
of this section.
Assessor May Request
Additional Information
Upon written request by the assessor,
taxpayers must make available to the
assessor all necessary books and records
relating to the ownership or use of
property which can help verify whether
ornotthepropertyqualiesforexemp-
tion.
Sale or Purchase of
Exempt Property
Property which is exempt from prop-
erty tax on January 2 and, due to sale or
other reason, loses its exemption prior
to July 1 of that year, will be placed on
the current assessment rolls for that
year.
e valuation will be determined with
respect to its value on January 2 of such
year.eclassicationwillbebasedon
the use to which the property was put
by the purchaser, or
in the event the purchaser has not uti-
lized the property by July 1, the intend-
ed use of the property, as determined
by the county assessor, based upon all
relevant facts.
Use of Information
e information on this form is re-
quired by Minnesota Statutes, section
272.02 to properly identify you and
determine if you qualify for this prop-
erty tax exemption. Your Social Secu-
rity number is required. If you do not
provide the required information, your
application may be delayed or denied.
Your County Assessor may also ask for
Penalties
Making false statements on this ap-
plication is against the law. Minnesota
Statutes, section 609.41 states that any-
one giving false information in order to
avoid or reduce their tax obligations is
subjecttoaneofupto$3,000and/or
up to one year in prison.
Questions?
Yourcountyassessor’soceshouldbe
abletoassistyouwithproperlylling
out this form.
Applying for Exemption from Property Tax