HomeMy WebLinkAbout20023126.tiff RESOLUTION
RE: APPROVE CERTIFYING THE NEED FOR THE PROVISION OF HEALTH CARE
SERVICES IN VARIOUS LOCATIONS WITHIN WELD COUNTY
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, NCMC Inc, as part of application for property tax exemption to the State
Property Tax Administrator, must provide a statement from the Board of County Commissioners
as to the need for the provision of health care services at those locations within Weld County,
and
WHEREAS, the locations of the properties in question are as follows:
1) Two office buildings located at 2010/2020 16th Street, Greeley, Colorado,
leased by Banner Health System, the Veterans Administration, and family
practice and general internal medicine physicians offices, and
2) 2000 70th Avenue, Greeley, Colorado, is occupied by a free-standing
ambulatory surgery center that is owned by NCMC and individual
physicians. In addition, there is currently under construction a medical
office building which will house physicians and outpatient services to be
provided by Banner Health System, and
3) 222 Johnstown Center Drive, Johnstown, Colorado, which contains a
medical clinic operated by Banner Health System which provides primary
care services to patients in the Johnstown area.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the need for the provision of health care services in Weld County
at the properties located at 2000 70th Avenue, Greeley, Colorado, 222 Johnstown Center Drive,
Johnstown, Colorado, and two office buildings located at 2010/2020 16th Street, Greeley,
Colorado. be, and hereby is, certified.
2002-3126
HS0009
(10 : //S
RE: CERTIFYING THE NEED FOR THE PROVISION OF HEALTH CARE SERVICES IN
VARIOUS LOCATIONS WITHIN WELD COUNTY
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 9th day of December, A.D., 2002.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST:
;� �'�� r ;- /ems
`-9 Glen
Weld County Clerk to the Board`:` ° >. -, C �� r
,1 tz.� ,Y
/ . c+ ` ! avid E. Lo , Pro-Tern
BY: //i _ .-
Deputy Clerk to the Boas i U 1t 0,2_-
.
C J. eile
APPROVED AS TO FORM: EXCUSED
r, L� illia H. J rke
dunty Attorn$y \ & \k'
LL
Robert D. Masden
/a
Date of signature: /7
2002-3126
HS0009
E.ESTHER Gesick- NCMC Property tax exemption Page 1
From: "Ellen E. Stewart" <estewart@gorsuch.com>
To: <LMORRISON@co.weld.co.us>
Date: 12/5/02 11:26AM
Subject: NCMC Property tax exemption
Hi Lee:
Thank you for spending time with me today regarding the property tax exemption applications a for
NCMC, Inc. As I mentioned on the phone, the state property tax exemption application under the section
regarding use of the facilities by physicians and dentists requires the following:
" Provide a statement from the Board of County Commissioners, certifying that there is a need for the
provision of health care services at this location."
The three locations being applied for by NCMC and the uses of the locations are as follows:
1. 2010/2020 16th Street, Greeley, Colorado. This property is across the street from the main hospital
building. It contains 2 office buildings. In one building the tenants are Banner Health System and the
Veterans Administration. In the other building there are physician offices. The physician offices include
family practice and general internal medicine. Banner Health Systems also has some space in the
second building as well.
2. 2000 70th Avenue, Greeley, Colorado. this property in west Greeley has a free standing ambulatory
surgery center that is owned by NCMC and individual physicians. In addition, there is currently under
construction a medical office building which will house physicians as well as significant outpatient
services to be provided by Banner Health System, an IRS 501 (c)(3)organization.
3. 222 Johnstown Center Drive, Johnstown, Colorado. This property is a medical clinic, which is
operated by Banner Health System and provides primary care services to patients in the Johnstown
area.
Hopefully this will provide you with enough information to meet the request of the state property tax
administrator. Thanks for your help on this.
Ellen
CONFIDENTIALITY NOTICE: The information contained in this e-mail is privileged and confidential, and
is intended only for the use of the individual or entity named above. If you are not the intended recipient,
you are notified that any disclosure, copying, distribution, electronic storage or use of this communication
is prohibited. If you received this communication in error, please notify us immediately by e-mail,
attaching the original message, and delete the original message from your computer and any network to
which your computer is connected.
CC: <BiII.Hughes@bannerhealth.com>
15-DPT-EX STATE OF COLORADO Division of Property Taxation use ONLY
FORM 901-A DIVISION OF PROPERTY TAXATION APP.#
REV. 11/00 DEPARTMENT OF LOCAL AFFAIRS
PHONE:303.866-2686 FILE#
TDD:303-866-5300 COUNTY
APPLICATION FOR EXEMPTION OF PROPERTY
OWNED AND uaru run a t nits I LY CHARITABLE OR SCHOOL PURPOSES
Every application for exemption from general taxation of real estate or personal property owned and used for schools or strictly charitable purposes must be
made on this form. A separate application must be filed for each separate parcel of property,as shown on county assessor's records,or each separate tax
area in which personal property is located. If you are applying for exemption of personal property only(furniture,equipment,etc.)and the county assessor's
records show the property listed at a single address with an actual value of$2,500 or less,you may not need to file this application. Contact the county
assessors office to determine whether your personal property qualifies for exemption pursuant to C.R.S.39-3-119.5.
Application for exemption of property owned and used for religious purposes cannot be made on this form,but must be made on the religious application
form prescribed by the Division of Property Taxation. Please call our office to request a copy of that form.
Please read the statutes and rules provided with this application prior to completing this application form.
The application should be typed or printed and completed in triplicate. You must complete Sections 1 through 13,as well as all sections indicated by each
category you mark in Section 13. The original and one copy must be mailed or delivered along with a$75.00 application fee to the county assessor of the
county wherein the property is located and one copy should be retained by the applicant for future reference. Make check oavable to Colorado Dent.of
Local Affairs. If the application is filed between June 1 and December 31,you must notify the County Treasurer that the application is pending in order to
keep the property from being sold at tax sale for non-payment of the prior year's taxes.
Attach additional sheets as needed and number them with the corresoondino section and ouestinn number. It is better to supply too much information than
not enough.
1. Owner name and mailing address: `: 2. Name andaddress of cantect person: '` '4 ' ` -.
Daytime Phone: Daytime phone:
3. Type of property(Check one or both):
❑ REAL( (Land,buildings,mobile g homes, leasehold improvements). PLEASE COMPLETE SECTION 4.
❑ not affixed to land or buildings). Please attach a list.
4. Legal description of REAL!p ope other rty,as itappears on assessment retards ordeed-Wietattachn enteas needed): ',
..
5. `Street'address/location of real orpersonal property(Use attachments as needed for complete directions):
1
6. Count/in which property'l Iodated:
7."Name ofcwner of rear orpersonal property"for which exemption Is being requested(If different from#1,;please.',
attach an explanation):
8.A. Date property was acquired B.` Date use of property for charitable C. Date construction or renovation
(As on deed or title.): or school purpose began: began, prior to use:for'charitable or
school purposes, if applicable:
(mo/day/yr) / / I (mo/day/yr) / / I I (mo/day/yr) / /
Pane t ,
2002-3126
.9_ ie,
. it:Urren�t Y3 U@S:xvrr a"4T'X*F:o- y""77e'*r s t"9�z rr" 34 _ 7,i7x-'.,...Land: [$ 1 Buildings and other improvements: [$ 1 Personal property: [$ 1
10. Owner/applicant"isS "
❑ Colorado not-for-profit corporation
❑ Out of state not-for-profit corporation (State of incorporation 1 Is this organization registered
to do business in Colorado? ❑ Yes ❑ No
❑ Unincorporated, non-profit association
❑ Partnership(Can only be granted exemption pursuant to 39-3-112 (3)(c)(II), (Ill)or(IV).)
❑ Trust
❑ For-profit Corporation (STOP--Exemption cannot be granted to property owned by a for-profit corporation.)
❑ Individual (STOP--Exemption cannot be granted to property owned by an individual.)
❑ Other(describe):
11. General information (to be corripleted by ell'applicants) `
A. Please attach copies of all of the owner's organizational rules or documents (including Articles of Incorporation. Bylaws,
Partnership Agreement. Constitution, etc.) NOTE: If the owner of the property is a Department of the United States
government, and the applicant is the lessee of the property, please attach copies of the lessee's organizational rules or
documents. If you are certain that you have previously filed these documents with our office, and if no changes have
been made since that time, you do not need to re-file them.
B. Please attach your organization's financial statements, including balance sheet and operatina statement, as of the end
of your last fiscal year.
C. Please attach any recent annual report compiled by your organization and/or any published brochures explaining
your organization and its activities.
D. Explain the purpose and activities of your organization (in your own words, not those of the organizational papers):
E. Describe. in detail. all uses of the subiect property(NOTE: Unused property CANNOT be granted exemption):
12. History. �„�,r _.� •vt' ,§r �. § �Kw >
'A. Has your organization applied for property tax exemption in Colorado before?J 1 Yes J 1 No
If"Yes", in what county? Previous File No:
What was the name the application was filed under?
B. Name of the prior owner of the subject property:
WITH REGARD TO THE REMAINDER OF THIS APPLICATION FORM:
*ALL APPLICANTS MUST COMPLETE SECTIONS 13, 24 & 25,AND AT LEAST ONE OTHER SECTION,AS
DETERMINED IN SECTION 13.
*IF THE PROPERTY WAS USED BY ANYONE OTHER THAN THE OWNER, YOU MUST COMPLETE SECTION 24.
YOU SHOULD INCLUDE USES BY INDIVIDUAL MEMBERS, IF THE USE WAS NOT SPONSORED BY YOUR
ORGANIZATION(E.G. PRIVATE PARTIES, WEDDING RECEPTIONS, ETC.).
13. Property is being used for
Check all applicable uses and complete all corresponding sections. If you do not fit one of the first nine specific categories
listed below, you must apply under the"Charitable Purposes: Non-Residential"statute. ("Residential" means average
occupancy exceeds 90 days.)
❑ School -- (39-3-107)-- Complete Section 14
❑ Licensed Health Care Facility-- (39-3-108(1)(b))-- Complete Section 15
❑ Domestic Water Company-- (39-3-108(1)(c))--Complete Section 16
❑ Amateur Sports Organization-- (39-3-108(1.3))--Complete Section 17
❑ Community Corrections Facility-- (39-3-108.5)--Complete Section 18
❑ Child Care Center-- (39-3-110)-- Complete Section 19
❑ Fraternal or Veterans Organization -- (39-3-111)-- Complete Section 20
❑ Health Care Services-- Used by Doctor-- (39-3-111.5)--Complete Section 21
❑ Charitable Purposes: Residential -- (39-3-109, 112, 112.5, & 113)--Complete Section 22
❑ Charitable Purposes: Non-Residential-- (39-3-108(1)(a))--Complete Section 23
❑ Used by Anyone Other Than Owner--(39-3-116)-- Complete Section 24
Pane 2
14.-Piopeity used for a sctroo = �' -r-"Pr'
(If your organization operates a kindergarten in connection with an elementary school system of less than six grades, or a
preschool or day care, you must also complete Section 19.)
A. Check the category/categories which describe your school:
❑ Pre-elementary ❑ Elementary ❑ Secondary ❑ Post-secondary ❑ Vocational ❑ Collegiate
❑ Other (Explain)
B. How does your curriculum compare to that of a public school?
C. Is daily attendance required? ❑ Yes ❑ No If"No", what is the school's policy on attendance?
D. What is the length of your school year?
E. What is the school's enrollment? (List number of students in each category.)
Full time students Boarding students Part time students Day students
F. Is this school accredited? ❑Yes ❑ No If"Yes", by whom?
G. Please provide a copy of your catalog, or other documentation describing your curriculum.
15. Property used for a licensedhealth'care
A.Attach a copy of the license issued by the Colorado Department of Public Health & Environment for the subiect property.
B. State the gross income derived by the owner from any unrelated trade or business activities (as defined in sections 511
through 513 of the"Internal Revenue Code of 1986,"as amended), at the subiect orooertv during the most recent fiscal
year: $
C. If you listed an amount under B, state the total gross revenues derived from the operation of this oroperty: j$
16. Property used for a domestic water Company:
A. Describe all improvements on the property:
B. List the Section(s), Township, and Range in which your buried water lines are located:
17. Proper-hi-used-for an amateuFsports`organization --nonce"sidential: "''
A. Is this organization organized and operated exclusively to foster local, statewide, national or international amateur
sports competition, and also organized and operated primarily to support and develop amateur athletes for national or
international competition in sports? ❑Yes ❑ No If"Yes", please provide documentation (e.g. copies of brochures,
referrals to stated purposes in Articles of Incorporation, etc.).
B. Describe how one may be eligible for membership in your organization:
18. Pronerti used as a CornmunitkCorrec'tions'Facility:' "
A. Attach proof of exemption from Federal income tax as determined by the Internal Revenue Service.
B. With which governmental agencies does your organization contract?
C. Do you provide residential accommodations? ❑Yes ❑ No
D. Explain how your organization provides programs and services to aid offenders in obtaining and holding regular
employment, in enrolling in and maintaining academic courses, in participating in vocational training programs, in
utilizing the resources of the community in meeting their personal and family needs and providing treatment, and in
participating in whatever specialized programs exist within the community.
19. Property used`for a cfi'itd"care centers'. *"
A. Is this facility licensed by the Colorado Department of Human Services? ❑Yes ❑ No If"Yes", please attach a copy
of the license.
B. Is tuition assistance available to the financially needy, or do you charge based on the ability to pay?
El N/A-- No fees chareed ❑ Yes ❑ No. If"Yes", complete the following, for your latest fiscal year:
* Gross revenues of your center: $
• Amount of tuition received: $
• Amount of waived or reduced fees for the financially needy: $
* Attach a copy of your sliding fee scale, if applicable.
* How do people find out that such aid is available?
• How do you determine who is eligible?
C. Attach a list of the center's staff, their job titles, and their salaries.
D. Attach a list of fees charged for each type of service offered.
oih
20. Property used`for a fi`rafema`o vterdne s organ:aatiori:" `"` "° ' `
A. Is this a branch, lodge, or chapter of a national or state wide organization? ❑ Yes ❑ No If"No", please complete
Section 23.
B. Is the property owner a holding company for a branch, lodge, or chapter? ❑ Yes ❑ No If"Yes", please provide
copies of the Articles of Incorporation, bylaws, and financial statements for the post or lodge, in addition to those
provided for the owner.
21. Property used'for health care services-=occupied by a physician'di dentist:`
A. Is property occupied or used by one or more physicians or dentists, licensed to practice in Colorado? ❑ Yes ❑ No.
B. Are the health care services offered at this facility available to all patients who request such services, and are there
provisions for fee waivers or reductions for the financially needy? 7 N/A-- No fees charged ❑ Yes ❑ No.
If"Yes", explain such provisions in detail (use attachment if necessary) including:
* How do you determine who is eligible?
* How much aid was given during your last fiscal year? $
* How do people find out such aid is available?
C. Provide a statement from the Board of County Commissioners, certifying that there is a need for the provision of such
health care services at this location.
22. Property used for strictly cherifatile purposes'--residental: ''
: ,
(If the average length of stay by the occupants of the subject property is LESS THAN 90 DAYS, please complete Section 23
rather than Section 22.) Check all applicable uses, then complete the required questions below, as indicated.
❑ Property is occupied by students attending an exempt school. (39-3-109 (1)(a))--Complete Question (a)on next page.
❑ Property is used as an integral part of a church, hospital, licensed health care facility, or organization whose property
is otherwise exempt, and is not leased or rented at any time. (39-3-109 (1))-- Complete Question (a) on next page.
❑ Property is occupied by persons receiving care or treatment from the owning hospital, licensed health care facility,
or institution for physical or mental disabilities, and, who, in order to receive such care or treatment, are required to
be domiciled within the subject facility. (39-3-109 (1)(b))-- Complete Question (a) on next page.
❑ Property is occupied as an orphanage. (39-3-112 (3)(a)(I))-- Complete Question(a) on next page.
❑ Property is owned by a nonprofit corporation, and is occupied by persons 62 years of age or over, or disabled, and
whose incomes are within 150%of the limits for the nearest low-rent public housing operated by a city or county housing
authority. (39-3-112 (3)(a)(II)(A))-- Complete Question(a) on next page.
❑ Property is occupied by single parent families whose incomes are within 150% of the limits for the nearest low-rent
public housing operated by a city or county housing authority. (39-3-112 (3)(a)(II)(B)). Facility must meet the
definition of"Family Service Facility"as defined in 39-3-112 (1)(b). Complete Questions (a), (b)and(i)on next page.
❑ Property is occupied by homeless or abused persons, whose incomes are within 150% of the limits for the nearest
low-rent public housing operated by a city or county housing authority. (39-3-112 (3)(a)(II)(C)). Facility must meet
the definition of"Transitional Housing Facility"as defined in 39-3-112 (1)(c). Complete Questions (a), (b), (c), and
(i)on next page.
❑ Property is owned by a limited partnership, of which a nonprofit corporation is a general partner, and partnership
was formed to obtain, and has been allocated, low income housing credits pursuant to Section 42 of the Internal
Revenue Code of 1986. Property is occupied by persons 62 years of age or over, disabled, homeless or abused, and
whose incomes are within 150%of the limits for the nearest low-rent public housing operated by a city or county housing
authority. (39-3-112 (3)(a)(II)(A)and (3)(c)(II))-- Complete Questions (a), (d)and(g)on next page.
❑ Property is owned by a limited partnership, of which all of the general and limited partners are nonprofit corporations,
and property is occupied by persons 62 years of age or over, disabled, homeless or abused and whose incomes are
within 150% of the limits for the nearest low-rent public housing operated by a city or county housing authority. (39-3-112
(3)(a)(II)(A)and (3)(c)(III)) -- Complete Questions (a) and(e)on next page.
❑ Property is owned by a limited partnership, of which each of the general partners is a for-profit corporation. Seventy-
five percent or more of the outstanding voting stock is owned by, and seventy-five percent or more of the members of
the board of directors are elected by one or more nonprofit corporations. Partnership was formed to obtain, and has
been allocated, low income housing credits pursuant to Section 42 of the Internal Revenue Code of 1986. Property is
an "elderly or disabled low income residential facility", as defined in 39-3-112 (1)(A.5), and is occupied by persons 62
years of age or over, or disabled, and whose incomes are within 150% of the limits for the nearest low-rent public
housing operated by a city or county housing authority. (39-3-112 (3)(a)(II)(A)and (3)(c)(IV))-- Complete Questions
(a), (f)and(g) on next page.
❑ Property is owned by the United States, and is leased to a nonprofit organization for the purpose of housing homeless
persons. (39-3-112.5)-- Complete Questions(a)and(h) on next page, and attach completed Questionnaire To
Determine Homeless Status for all tenants occupying this property for the period under application.
(Continued on next page)
.." '[ t c.z,A.i. ..1'T-sptstswr.. , Y*4 s,A,x 3' iwV` r ' v3;.
Question (al
Is the property occupied only by those categories of persons which you have checked on the preceding page?
❑ Yes ❑ No If"No", please indicate who else occupies the property, and explain:
Question (131
Does your organization provide counseling in such areas as career development, parenting skills, and financial
budgeting? ❑ Yes ❑ No If"Yes", please attach documentation.
Question (cl,
Is your organization's purpose to facilitate the achievement of independent living by your tenants within a 24 month
period? ❑ Yes ❑ No If"Yes", please attach documentation.
Question (di
(I) Please attach the nonprofit general partner's Articles of Incorporation, bylaws, and financial statements.
Question (el
Please attach the Articles of Incorporation, bylaws, and financial statements for all of the general and limited
partners.
Question (f)
Please attach the Articles of Incorporation, bylaws, and financial statements for all nonprofit corporations
which own seventy-five percent of the voting stock of, and elect seventy-five percent or more of the board of
directors of, the general partners.
Question lal,
(I) If not clearly stated in the Partnership Agreement which you have attached, state the purpose of the partnership:
(II) Attach documentation that the partnership has been allocated low income housing credits pursuant to Section
42 of the "Income Tax Code of 1986."
(III)Attach a copy of all financial statements of the partnership for the entire"compliance period", as defined by
Section 42 (i)(1)of the"Internal Revenue Code of 1986".
Question (h1
(I) Attach a copy of the nonprofit entity's Articles of Incorporation and bylaws.
(II) Attach a copy of the lease between the agency of the United States and the nonprofit organization.
(III)Attach a copy of the rental agreement between the nonprofit organization and the individuals or families to be
housed in such property.
NOTE: You must provide copies of new rental agreements after each change of tenants, and account for all
periods of vacancy between tenants.
Question (il
(I) Attach documentation that your organization has received exemption under section 501 (c)(3)of the Internal
Revenue Code.
23. Property'used for str`icfl'y'cha"ritabiepurposes"-=nonresidentiai,
1. Please explain in detail why you think your organization is charitable, and provide any available documentation.
Receipt of 501(c)status from the I.R.S. cannot be equated with eligibility for property tax exemption. Your explanation
should discuss the charitable activities of your organization, especially as they relate to the subject property:
2. Who benefits from the efforts of your organization?
3. Is there a policy for waiving/reducing the fees for your services? ❑ N/A-- No Fees Charged ❑ Yes ❑ No. If"Yes",
explain the policy in detail (use attachment if necessary), including but not limited to:
* How do you determine who is eligible?
* How much aid was given during your last fiscal year? $
* How do people find out such aid is available?
24. Property used-by`anyone'ot(ierthan
In the spaces below, or on an attachment, provide the following information for your most recent fiscal year:
(A) The names of all persons, groups, etc. which have used your property. Include those uses by members of your
organization where the member, and not the owner, was primarily responsible for the content of the activity(e.g. a
member used the property for an anniversary party). If there were no users, state"NONE."
(B) An estimate of the number of times that each of those persons, groups, etc. used the property.
(C) If the owner received any money from these users (i.e. rental payments, donations, etc.), provide the amount of
income which was received from each user. If no income was received from a user, state"NONE".
NAME OF USER I #OF USES I TOTAL AMOUNT RECEIVED
I I
I I
I I
I I
I I
I I
NOTE: Applicants may be required to provide additional information regarding any use of the property by outside entities.
25. Signature and verification (to be completed by all applicants)
I declare under the penalty of perjury in the second degree, that I have examined this application, including any accompanying
statements and documents, and to the best of my knowledge and belief, it is true, correct and complete.
SIGNATURE DATE
NAME OF SIGNATORY TITLE
"IMPORTANT REMINDERS:
1) Failure to supply complete or accurate information may result in denial. Please review your answers before mailing.
2) Be sure to provide information for all portions of the property, including any vacant/unimproved areas.
3) A separate application and fee is required for each parcel of real property, or for each tax area for personal property.
Consult your assessor if unsure how many parcels/tax areas are involved.
4) This application must be submitted through your County Assessor. Failure to do so will result in substantial delays in
processing your request.
5) We cannot review your request until the filing fee is paid in full.
This Portion to belCo mpleted bytheccounty`Assessor`,
Please complete the following questions with respect to the subject property. Forward the original of the application form and attachments to the Division of
Property Taxation,along with the applicant's check. Retain one copy of the application for your files. You will receive a copy of our determination.
A. Date application was received in your office: / /
B. Legal description (item#4)or location of personal property(item #5) 0 is correct ❑ is incorrect.
If incorrect, please provide correct information:
C. Name of owner(item #7) 0 is correct IT is incorrect. If incorrect, state correct name of owner:
D. Date deed recorded: / / in book page
E. Parcel I.D. No(s):
(If more than one parcel, please identify each parcel by legal description.)
F. Tax Area(s):
(If more than one, please identify which locations are in which tax areas.)
G. ACTUAL value is: Land $ Improvements$ Personal $
H. PLEASE PROVIDE COPIES OF THE PROPERTY ASSESSMENT CARD AND A PLAT OF THE AREA.
Date: / / COUNTY ASSESSOR:
(BY:
Page 6
STATE OF COLORADO 1313 Sherman St.,#419
15-DPT-EX DIVISION OF PROPERTY TAXATION Denver,CO 80203 .
FORM 901-AA DEPARTMENT OF LOCAL AFFAIRS
REV. 12/96 PHONE:303.866-2686
TDD:303-866-5300
QUESTIONNAIRE TO DETERMINE 'HOMELESS' STATUS
TO BE COMPLETED ONLY BY THE NONPROFIT LESSEE OF PROPERTY OWNED BY THE
UNITED STATES AND FOR WHICH EXEMPTION IS BEING SOUGHT PURSUANT TO 39-3-112.5
Please make several copies of this form; it must be used not only during the application process, but also during subsequent
years if the exemption is granted. For an initial application for exemption, one copy of this form must be completed for each
tenant who has occupied this property during the past two years.
For filing with the annual Exempt Property Report following the granting of the exemption, one copy of this form must be
completed for each tenant who occupied this property during the previous calendar year.
Name of organization leasing from U.S:
Address of property:
Name of tenant:
Dates of occupancy by this tenant: / / to / /
1. Immediately prior to occupying a housing facility for the homeless:
(a) Did the individual or family have a primary night time residence that was a supervised publicly or privately
operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate
shelters, and transitional housing for the mentally ill, but excluding prisons or other detention facilities)?
❑ Yes ❑ No If"Yes", name that location:
(b) Did the individual or family have a primary nighttime residence that was a public or private place not designed for,
or ordinarily used as, a regular sleeping accommodation for human beings? D Yes ❑ No If"Yes", name that
location:
(c) Was the individual or family at imminent risk of homelessness because they faced immediate eviction and have
been unable to identify a subsequent residence, which would result in emergency shelter placement?
❑ Yes ❑ No If"Yes", explain the situation in detail:
(d) Had the handicapped individual been released from an institution, and were they at risk of imminent
homelessness because no subsequent residences were identified?D Yes ❑ No If"Yes", explain the situation
in detail:
2. Is there any other information regarding this tenant's condition of homelessness that you wish to address?
❑ Yes ❑ No
If"Yes", explain:
SIGNATURE AND VERIFICATION:
II declare, under penalty of perjury in the second degree, that I have examined this document, including any accompanying
statements, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature: Date / /
Name of Signatory: Title:
Rane7,
STEPVI ROGGFf"RHEtExEMPTIOwPROCESS
When Applying:
* Determine whether you need to file this application form. If you are applying for exemption of personal property only
(furniture, equipment, etc.) and the county assessor's records show the property listed at a single address with an actual
value of$2,500 or less, you may not need to file this application. Contact the county assessor's office to determine
whether your personal property qualifies for exemption pursuant to C.R.S. 39-3-119.5.
* Complete all relevant forms carefully and thoroughly.
Sign and date the application.
*Send the original and one copy of those forms, including all supporting documents, to the County Assessor's office of
the County in which the property is located.
* Be sure the application fee of$75.00 is securely attached to the application. Make checks payable to Colorado
Department of Local Affairs.
* Be sure the proper mailing address and correct phone number are on the form.
* Be sure there is a person listed who we can contact should we need further information.
*You will receive a card from the Division of Property Taxation indicating that your application has been received. That
card will include an application number. Please use this number on all follow-up correspondence.
* By filing an application for exemption, you are assuming the responsibility to demonstrate clearly that the property
qualifies for exemption. The Division may require additional information, in accordance with current laws. If you have
any questions regarding a request for information, feel free to call before responding.
While the application is pending:
*An examiner may need to contact you for additional information.
*An examiner may drop by at any time.
* Inform us of any change in address or phone number.
If we issue a Tentative Determination denying part or all of the exemption:
*Contact the examiner whose name is on the form if you have any questions.
* If you are not satisfied, you may request a public hearing within 30 days of the date of the Tentative Determination.
* If you understand and wish to accept our decision you may waive your right to a public hearing.
Upon the issuance of a final Determination:
*You may appeal the Property Tax Administrator's decision to the Board of Assessment Appeals within 30 days of the
date of that final determination.
After any exemption is granted:
*The Division of Property Taxation will send an Exempt Property Report to you around the first of March of each year,
following the year in which the determination granting the exemption was issued. You will need to complete and return
that Exempt Property Report to us, along with the$25.00 filing fee, by April 15.
* Keep us informed as to any change in mailing address or telephone number. Failure to do so may result in loss of
exemption.
* Notify us promptly of any transfer of ownership of the property.
If you have any questions regarding property tax exemptions statutes:
* Review Article X, Section 5 of the Colorado Constitution, and the following Colorado Revised Statutes: 9-3-101 through
39-3-135; 39-1-102; and 39-2-117. The Colorado Revised Statutes should be available at your local library.
*Contact our office at 303-866-2686.
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