CERTIFICATION OF THE VALUE ADJUSTMENT BOARD



RETURN OF POLLUTION CONTROL DEVICES

FOR AD VALOREM TAX PURPOSES

Section 193.621, Florida Statutes and Rule 12D-1.004(1)(b), F.A.C.

File this form with your county property appraiser by April 1. Keep a copy for your records.

|Taxpayer |      |County |      |

|Address |      |Phone |      |

| | |Fax |      |

|This return is for the assessment of the pollution control devices below. (Fields will expand, as needed.) |

|Description of property: |

|      |

|Description of facility: |

|      |

|I will furnish any reasonable information the property appraiser may request for this return. |

| | |

A property appraiser may ask the Department of Environmental Protection to make a recommendation about whether a taxpayer is entitled, in whole or in part, to an assessment limit under Section 193.621, F.S. You will be notified if a recommendation is requested. You may wish to familiarize yourself with the requirements of that statute before making an application with your county property appraiser.

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DR-492

R. 11/12

Rule 12D-16.002

Florida Administrative Code

Effective 11/12

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