Form AV-10
(Rev. 03-14)
APPLICATION for TAX YEAR ______________
Property Tax Exemption or Exclusion
COUNTY: ____________________ MUNICIPALITY: _________________
Full Name of Owner(s):____________________________________________________________________________________________
Trade Name of Business:______________________________________________________________________________________
Mailing Address of Owner:_________________________________________________________________________________________
Phone Numbers: Home: _________________________ Work: ____________________________ Cell: _______________________
List the Property Identification Numbers and addresses/locations for the properties included in this application (attach list if needed):
Property ID #: _________________________ Address/Location:___________________________________________________________
Property ID #: _________________________ Address/Location:___________________________________________________________
Property ID #: _________________________ Address/Location:___________________________________________________________
Non-Deferment Exemptions and Exclusions
—Check or write in the exemption or exclusion for which this application is made.
These exemptions or exclusions do not result in the creation of deferred taxes. However, taxes for prior years of exemption or exclusion
may be recoverable if it is later determined that the property did not actually qualify for exemption or exclusion for those prior years.
[ ] G.S. 105-275(8) Pollution abatement/recycling [ ] G.S. 105-278.5 Religious educational assemblies
[ ] G.S. 105-275(17) Veterans organizations [ ] G.S. 105-278.6 Home for the aged, sick, or infirm
[ ] G.S. 105-275(18),(19) Lodges, fraternal & civic purposes [ ] G.S. 105-278.6 Low- or moderate-income housing
[ ] G.S. 105-275(20) Goodwill Industries [ ] G.S. 105-278.6 YMCA, SPCA, VFD, orphanage
[ ] G.S. 105-
Solar energy electric system [ ] G.S. 105-278.6A CCRC-Attach Form AV-11
[ ] G.S. 105-
Charter school property [ ] G.S. 105-278.7 Other charitable, educational, etc.
[ ] G.S. 105-277.13 Brownfields-Attach brownfields agreement [ ] G.S. 105-278.8 Charitable hospital purposes
[ ] G.S. 105-278.3 Religious purposes [ ] G.S. 131A-21 Medical Care Commission bonds
[ ] G.S. 105-278.4 Educational purposes (institutional) [ ] Other: ______________________________
Tax Deferment Programs
—Check the tax deferment program for which this application is made. ***These programs will result in
the creation of deferred taxes that will become immediately due and payable with interest when the property loses eligibility. The
number of years for which deferred taxes will become due and payable varies by program. Read the applicable statute carefully.***
[ ] G.S. 105-275(12)
[ ] G.S. 105-275(29a)
Nonprofit corporation or association organized to receive and administer lands for conservation purposes
Historic district property held as a future site of a historic structure
[ ] G.S. 105-277.14 Working waterfront property
[ ] G.S. 105-277.15A Site infrastructure land
[ ] G.S. 105-278 Historic property-Attach copy of the local ordinance designating property as historic property or landmark.
[ ] G.S. 105-278.6(e) Nonprofit property held as a future site of low- or moderate-income housing
Describe the property: ____________________________________________________________________________________________
Describe how you are using the property. If another organization is using the property, give their name, how they are using the
property, and any income you receive from their use: __________________________________________________________________
AFFIRMATION: I, the undersigned, declare under penalties of law that this application and any attachments are true and correct to
the best of my knowledge and belief. I have read the applicable exemption or exclusion statute. I fully understand that an ineligible
transfer of the property or failure to meet the qualifications will result in the loss of eligibility. If applying for a tax deferment
program, I fully understand that loss of eligibility will result in removal from the program and the immediate billing of deferred taxes.
Signature(s) of Owner(s): _____________________________________Title: __________________________Date: _______________
(All tenants of a tenancy _____________________________________Title: __________________________Date: _______________
in common must sign.) _____________________________________Title: __________________________Date: _______________
The Tax Assessor may contact you for additional information after reviewing this application.
OFFICE USE ONLY: [ ] APPROVED [ ] DENIED BY: _____________________________ REASON FOR DENIAL: ______________________________________________