_ covnjyof'^ SmCOESS Page 2 LANDLORD / PROPERTY OWNER DECLARATION FORPROPERTY TAX REBATES Thisapplication is due the last day ofFebruary ofthe yearfollowing the taxation year to which the application relates. Name of Landlord / Owner (please print) Mailing Address Telephone No. i L Assessment Roll No. 43 Property Occupied by Registered Charity (Full Address) Total Annual PropertyTaxes Payable on Assessed Property $_ This amountshouldagree to Municipal tax notices Total Annual Property Taxes charged to Charity this year $_ Registered Charity's Proportional Share of Rentable Space of Property % "B' I certify that the above information is true, correct and complete. Signature of Landlord / Owner Date Name of Landlord / Owner FOR OFFICE USE ONLY Local Municipality: Application No. Taxation Year For Which Rebate Is Requested: Date Application is received:. Charitable Status Verified: Amount Eligible for Rebate 40% x "A" OR Amount Eligible for Rebate 100% x "A" Distribution of Rebate: Local Municipality $ County of Simcoe $ Education $ Total $ Approved by Date This property tax rebate program is pursuant to and governed by County of Simcoe By-lawNo. 6104.' January, 2012 _ COVNJYOF'-Z^ SIMCOEMH APPLICATION FOR PROPERTY TAX REBATE FOR REGISTERED CHARITIES AND SIMILAR ORGANIZATIONS PURSUANT TO COUNTY OF SIMCOE BY-LAW NO. 6104 This application is due the last day of February of the year following the taxation year to which the application relates. Pleaseensurethat the Landlord/ PropertyOwnerDeclaration on thesecondpage of thisform is completedif the propertyisleased. This application consists of2 parts, the applicant'sdeclaration and the landlord'sdeclaration, both of which must befullycompleted(ifapplicable) priortosubmission. Name of Registered Charity Attach proof ofstatus as Registered Charity as defined in S. 248(1) ofthe Income Tax Act (indicate type of document) Revenue Canada Charitable Registration Number Property Address _ Name of Contact Mailing Address (if different from above) Telephone No. [ I Fax: () Email: Annual Property Taxes Paid This Year s "A" Thisamountshould agree to Amount "A"on Property Owner Declaration Organization's Share of Rentable Space of Property % "B" Thisamountshould agree to Amount "B"on Property Owner Declaration Icertify that the above information Istrue, correct and complete. Iauthorize the release by third parties of all information the County Treasurer or Local Treasurer may require to verifythe accuracy of any information submitted with this application. Ialso acknowledge that I must Informthe Local Municipality of any changes in the above which affects my eligibility for a rebate. Signature of SigningOfficer Name and Title of Signing Officer Date Personal Information Iscollected on this form per County of SImcoe By-law No. 6104 and willbe used to determine eligibilityfor property tax rebates for registered charities. Ifyou have questions, contact the Treasurer at your local municipality. Submit the request to your Local Municipality: Town of Bradford West Gwllllmbury; Town of Collingwood; Town of Innisfil;Town of Midland; Town of NewTecumseth; Town of Penetanguishene; Town of Wasaga Beach;Township of Adjala-Tosorontio;Township of Clearview; Township of Essa;Township of Oro-Medonte; Township of Ramara; Township of Severn; Township of Springwater; Township of Tay; Township ofTiny. This property tax rebate program is pursuant to and governed byCountyof SImcoeBy-law No.6104.' January, 2012.