4. Street address or
location of property
5. a) Title to this property is in the name of
b) Address of owner
6. If title holder is dierent from
the applicant, please explain
7. Title holder is £ A nonprot corporation £ An unincorporated association/organization
£ An individual £ Other
8. Exact date title was acquired 9. Title was acquired from
Please attach copy of the deed.
10. Does the applicant have a lease or land contract for this property?
If yes, please attach a copy.
11. Amount paid by title holder for the property
12. Exact date the exempt use began
13. Under what section(s) of the Ohio Revised Code (R.C.) is exemption sought?
R.C. R.C. R.C.
14. How is this property being used? Do not give conclusions such as charitable purpose, public worship or public purpose.
Be specic about what is being done on the property and who uses it. If the property is not currently being used, but
there is an intent to use it later for an exempt purpose, describe the intended use and the date set for the intended use.
15. During the years in question, was any part of this property (check one):
a) Leased or rented to anyone else? £ Yes £ No
If yes, please attach copy of lease agreement.
b) Used for the operation of any business? £ Yes £ No
c) Used for agricultural purposes? £ Yes £ No
d) Used to produce any income other than donations? £ Yes £ No
Note: If the answer to any part of question 15 is “yes,” enclose all details on a separate sheet of paper. If money
is received, submit prot and loss statements, income and expense data, balance sheets or any other nancial
16. Is anyone living or residing on any part of this property? £ Yes £ No
If yes, answer the following:
a) The person’s name and position
b) The resident’s duties (if any)
in connection with this property
c) The rent paid or other
17. Is anyone using this property other than the applicant?
£ Yes £ No
If yes, please enclose a complete, detailed explanation.
18. Does the applicant own property in this county that is already exempt from taxation?
£ Yes £ No
19. Property use for charitable purposes.
Please provide articles of incorporation, constitution or bylaws, IRS determination letter and any other similar relevant information.
20. Property used for senior citizens’ residences.
If the purpose of the property is to provide a place of residence for senior citizens, submit all information required by
R.C. section 5701.13.
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