BEFORE THE COUNTY APPRAISER OF DONIPHAN COUNTY, KANSAS

IN THE MATTER OF QUALIFICATION OF PARCEL NO.  

FOR PARTICIPATION IN NEIGHBORHOOD REVITALIZATION PLAN.

APPLICATION TO QUALIFY AND PARTICIPATE

Part I

1. OWNER'S NAME   2. OWNER'S SOCIAL SECURITY NO:

3. (A) OWNER'S MAILING ADDRESS:   (B) OWNER'S DAY PHONE NO.

4. PROPERTY ADDRESS

5. LEGAL DESCRIPTION OF PROPERTY:

6. APPLICATION FEE $25.00            7. BUILDING PERMIT NO. (if applicable)

INTENDED USE AND CLASSIFICATION OF PROPOSED IMPROVEMENT
(Check the box next to the word applicable in 8,9,10, 11 below)

8. RESIDENTIAL  COMMERCIAL    INDUSTRIAL   AGRICULTURAL   RECREATIONAL   OTHER

9. NEW      REHABILITATION

10. RENTAL    OWNER OCCUPIED

11. If residential: SINGLE FAMILY      MULTI-FAMILY       NUMBER OF UNITS

12. (A) DESCRIBE PROPOSED IMPROVEMENTS; (Also attach drawings with dimensions.)

        (B) BUILDINGS TO BE RAZED, IF ANY: 

13. ESTIMATED DATE CONSTRUCTION TO BE COMMENCED (xx/xx/xxxx)

14. ESTIMATED DATE CONSTRUCTION TO BE COMPLETED   (xx/xx/xxxx)

15. ESTIMATED COST OF IMPROVEMENTS:    MATERIALS  $
                                                                                  LABOR          $
                                                                                  TOTAL           $

16. Applicant agrees and acknowledges that (a) Applicant has received, read and understands the criteria for qualification and the procedure to be completed to qualify, (b) applicant will follow all required procedures, (c) within 15 days after completion, applicant will report such completion to the County Appraiser, (d) If construction is not completed January 1st following approval of this application, applicant will report such fact to County Appraiser prior to January 15th next following, (e) any approval issued pursuant to this application becomes null and void one year from date of approval if construction not commenced prior to the expiration of such one year period, and (f) if construction is not completed on the second January 1st following County Appraiser's approval under Part II, then such approval becomes null and void and all construction completed, if any, will not be eligible to participate in the Rebate Program.

Under Penalty of perjury, I hereby state that all information contained in the above application is true and correct.

________________________________________________________________     _______________
Landowner's Signature                                                                                                   Date

COUNTY APPRAISER'S ACTION ON APPLICATION

PART II

Subject to meeting the minimum expenditure requirement of $5,000.00 and meeting the minimum increase in appraised value directly attributable to the improvement requirement of $5,000.00, the above application is hereby

CONDITIONALLY APPROVED                                                       DENIED 

________________________________________________________________     _______________
County Appraiser                                                                                                          Date