Owner-Builder Written Declaration
I am an owner-builder who declares the following to subcontractors working on the project described below:
I am improving the property named below for sale; and I will be liable for the city or town privilege tax for
such contracting activity; and I have a valid city or town privilege license number as shown below. This
declaration is made in accordance with Model City Tax Code section 415(c)(2).
A separate “Owner-Builder Written Declaration” is needed for each project.
A. Owner Name: _______________________________________________________________________________
B. Owner Address: ______________________________________________________________________________
(Full address of owner)
C. Owner Phone:
D. City or Town of _________________________ Privilege License Number:_______________________________
E. Job Address: _________________________________________________________________________________
(Full address of job)
F. Subdivision Name: ____________________________________________________________________________
G. Lot Number: __________ Book/Map/Parcel: _________ - __________ - __________
H. Check the Project Type: _______ Residential structure: ______ Lot without structure
_______ Other – describe: ____________________________
I. Issued to: _____________________________________________________________________________________
(Name of subcontractor)
(Full address of subcontractor, including phone no.)
I certify that the above information is correct and that I understand that making a false or fraudulent claim to aid or
abet another to obtain a city or town privilege tax exemption is a Class One Misdemeanor [pursuant to Model City
Tax Code section 580].
Owner-Builder Signature: ___________________________ Print Name: ___________________________________
Title: _________________________________________ Date:__________________________________________