Btla A 9 Form – Fill Out and Use This PDF

Form BTLA A-9

Page 1

The State of New Hampshire

List of Real Estate and Personal Property on which Exemption is Claimed

Pursuant to RSA 72:23-c

This form must be filled in and filed annually before April 15. The ORIGINAL list must be filed with the selectmen (assessors) of the town (city) in which such property is located. A DUPLICATE copy should be retained by the applicant. Failure to file this list may result in denial of the exemption.

This is to certify that the answers to the following interrogatories are true and correct to the best of my knowledge and belief and that I am duly authorized to sign on behalf of the applicant organization.

Date:

Signed by:

NAME

TITLE

1.Name of applicant organization:

(OWNER OF PROPERTY OR PRINCIPAL OCCUPANT – CIRCLE ONE OR BOTH

2.Mailing address and telephone number:

3.In what municipality is this exemption claimed?

4.Under which section is applicant requesting exemption: (An organization may not claim multiple exemptions under separate provisions of RSA 72:23)

RSA 72:23 III (religious)

RSA 72:23 IV (educational)

RSA72:23 V (charitable)

(Form A-12 must also be filed, if applicant is requesting exemption as a charitable organization.)

5.Is the applicant organization organized or incorporated in New Hampshire (Yes _____ No _____ ) Does it have a principal place of business in this state (Yes ____ No ____ ). If yes, where:

ADDRESS

TELEPHONE NUMBER

6.State general purpose for which applicant is organized or incorporated:

7.If applicant is requesting exemption as a charitable organization under RSA 72:23, V:

(a)What service of public good or welfare is provided?

(b)Who are the beneficiaries of this service?

(c)Is there a charge for this service? ________ If yes, explain

(d)For what purpose is any income used?

8.If the applicant is a religious organization, is it a regularly recognized and constituted denomination, creed or sect? If so, give its generally recognized name