AFFIDAVIT June 2013 Section ________Township________ ________________________________________________ Range__________ (Print Name EXACTLY as shown on Tax Assessment) Tax Assessor No_________________ 7-13-2529 of the MT MCA states: "may be exempt upon request and with approval of the Board of Trustees, from payment of the tax for the support of SHTVD on the following grounds": Mark CLEARLY below a, b,c or d. a. Does not receive the signal of any television translator station of the Swan Hill TV District as a result of a geographic obstruction. b. Receives direct reception from the TV station from which SHTVD receives it’s signal. c. Receives services through the medium of a community antenna system (cable) and is in good standing with them and do not benefit from the SHTVD translator system. [requires that you submit a Optimum or similar pay stub] d. A vacant piece of property in not liable for the tax. This MCA was repealed in 2009 in SB 57 but is grandfathered in by the saving clause [Sec 42] in SB 57 Section 42. "Saving clause. [Sections 1 through 20] do not affect rights and duties that matured, penalties that were incurred, or proceedings that were begun before July 1, 2009". I acknowledge that Section 70-424 R.C.M. 1947 ( revised MCA 7-11.1001-1029 MCA 2009 ) provides: “Any person or persons who shall make a false statement or fraudulent claim for exemption as provided in this act shall be guilty of a misdemeanor.” I understand the Swan Hill Trustees have the right to validate all claims for exemption. I execute this affidavit with the full knowledge and awareness of the penalties for perjury and false swearing in the State of Montana. Proper ty Address________________________________Assessor#_________________________ School District in which property is located____________________ City _____________________Zip ____________County_________________ Date _________of __________________20__ _____________________________ ( Your Signature) Notary Subscribed and sworn to me this____________ date of ___________, 20____ (Seal) Notary Public for the State of Montana Name________________________________ Residing At________________ Address____________________________ City _____________ Zip_________ My Commission expires__________________________________ Mail to: Swan Hill TV District Channels 34.1 TNN 34.2 Retro 34.3 PBJ PO Box 530 7.1 KSPS PBS Spokane 34.4 QVC 34.5Cars TV 34.6 FamNet 34.7 RTV News 34.8 ION Bigfork, MT 59911 8.1 CBS & 8.2 CW 9.1 NBC, 9.2 METV & 9.3 THIS TV 42.1 & 42.2 ABC & FOX http://www.swanhilltv.net 21.1 & 21.2 – EBRU & AJE 46.1 KUKL PBS 46.2 PBS Kids [email protected] 27.2 KSKC 46.3 Create 46.4 World 46.5 MT Leg 101.3 KUFM Public Radio Swan Hill TV District is a regularly formed and organized non-profit organization formed under Chapter 4 of Title 70, R.C.M. 1947 as amended. In accordance with these statues a special tax is levied on the residents of the area served by the TV district to meet necessary budget expenses. This affidavit MUST be received by the Board of Trustees of Swan Hill TV District by July 1st of the current tax year in order to void it from assessments arriving the following November. A request for voiding the assessment based on having cable MUST include pay a stub [or copy] from the last three months. Remarks: .