hampton_exemption_classification_form Revised 10/26/2015 Page 1 of 3
City of Hampton Parcel Identification Number ______________
Exemption by Classification Application
Office of the Assessor of Real Estate
This form may be submitted to the Office of the Assessor of Real Estate (1 Franklin St., Suite 602, Hampton, VA 23669-
3580) to claim exemption by classification pursuant to Article X, Section 6(a)(1) through (4) of the Virginia Constitution, or
pursuant to the Code of Virginia, 58.1-3606 and 58.1-3609, in lieu of a letter containing the same information.
_____ Check here if a personal property exemption is also being requested
Complete a separate application for each individual parcel of real estate for which an exemption is being sought.
Parcel Identification Number/LRSN ____________________________ Date Purchased _________________________________
Land Assessment _________________ Improvement Assessment _________________ Total Assessment __________________
Property Address _________________________________________________________________________________________
Property Owner ___________________________________________________________________________________________
Mailing Address __________________________________________________________________________________________
Name, Title and Contact Information (Telephone, Email, Fax) of official representatives that might be contacted if there are
questions.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
1. Is the property owner chartered or incorporated under the laws of the Commonwealth of Virginia”
Yes ______ No _____
2. For what purpose is the owner chartered, incorporated, or otherwise in existence?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3. Please provide a specific explanation of the use of the property
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. Does any individual or entity other than the property owner occupy or use any part of the property?
_______________________________________________________________________________________________________
5. Is any income received from the use of any portion of the property whether considered as rent or reimbursement of
services incurred?
Yes ______ No _____
If yes, provide details ______________________________________________________________________________________
_______________________________________________________________________________________________________
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6. Under sections A, B or C please check the qualifying use for which exemption is being sought (one only).
A. Article X, Section 6 of the Constitution of Virginia current qualifying uses;
____ owned and exclusively occupied by churches or religious bodies for religious worship or for residences of their ministers
____ private or public burying grounds or cemeteries, not operated for profit
____ public libraries or institutions of learning not conducted for profit
____ land subject to a perpetual easement permitting inundation by water
B. If land acquired before July 1, 1971 these uses may qualify;
____ YMCA and similar religious associations 58.1-3606(A)5
____ parks and playgrounds held by trustees for perpetual use of the general public 58.1-3606(A)6
____ benevolent and charitable organizations used exclusively for lodge purposes or meeting rooms 58.1-3606(A)7
____ nonprofit corporations organized to establish and maintain a museum 58.1-3606(A)8
C. If land acquired on or after July 1, 1971, these uses may qualify;
____ volunteer fire departments and rescue squads 58.1-3610
____ boys clubs affiliated with the Boys Clubs of America, Inc. 58.1-3611
____ auxiliaries of the Veterans of World War I, USA, Incorporated 58.1-3612
____ Societies for the Prevention of Cruelty to Animals 58.1-3613
____ Boy Scouts and Girl Scouts of America and their subsidiaries 58.1-3614
____ Home Demonstration Clubs, 4-H Clubs and Future Farmers of America 58.1-3615
____ American National Red Cross and local chapters 58.1-3616
____ religious and charitable organization 58.1-3617
____ College alumni associations and foundations 58.1-3618
____ The State Future Farmers of America, Future Homemakers of America and Future Business Leaders of America 58.1-3619
____ Farm club associations 58.1-3621
____ Habitat for Humanity and local affiliates 58.1-3622
7. Does the applicant have an exemption from taxation under the Internal Revenue Service Code, Section 501c or any other
provision of the Internal Revenue Service Code?
Yes, 501c ______ Yes, other ______ No ______
If yes, please provide IRS identification number _____________________ and the date of the IRS ruling ____________________
8. Does the applicant have a license for serving alcoholic beverages issued by the Virginia Alcohol Beverage Control Board
for use on this property?
Yes ______ No _____
If yes, please explain ______________________________________________________________________________________
_______________________________________________________________________________________________________
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9. Please attach the following supporting documents
_____ The most recent financial statements or forms filed with the IRS reflecting income and expenses for the most recent
12-month reporting period.
_____ A list of names of all current trustees
_____ A list of the names and compensation of all directors, officers and employees of the organization
10. Does any part of the organization’s net earnings inure to the benefit of any individual?
Yes ______ No _____
If yes, please explain ______________________________________________________________________________________
_______________________________________________________________________________________________________
11. Please describe any activities of the organization that involve lobbying efforts or otherwise attempt to influence legislation.
Also describe if the organization participates in any political campaigns on behalf of any candidate for public office.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please certify to the following statement, or provide an explanation why you cannot.
I certify that the applicant has no rule, regulation, policy, or practice that unlawfully discriminates on the basis of religious
conviction, race, color, sex, or national origin.
ORGANIZATION: _________________________________________________________________________________________
By: Officer’s Name _______________________________________________
Officer’s Title _________________________________________________
Date _______________________________________________________
STATE OF VIRGINIA
CITY OF HAMPTON
______________________________________________ (Officer’s Name) being duly sworn, deposes, and states that as the
______________________________________________ (Officer’s Title) of __________________________________________
(Legal Name of Ownership Organization), he or she has read this application and knows the contents thereof and that the matters
stated are true.
______________________________________________
(Signature of Officer)
Subscribed and sworn to before me this ______________ day of ___________________________________________________
STATE ________________________________________
CITY __________________________________________
______________________________________________
(Notary Public)
My commission expires: ___________________________
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