Free BEFORE THE BOARD OF TAX APPEALS OF THE STATE OF KANSAS - Kansas

BEFORE THE COURT OF TAX APPEALS OF THE STATE OF KANSAS Industrial Revenue Bond Informational Statement (K.S.A. 12-1744a) APPLICANT:

(For State of Kansas use only)
__________________________________________ City or County issuing I.R.B.s __________________________________________ County in which City is located

Please answer all questions. If a question is not applicable, please indicate (N/A).

IRB Statement No.________________-IRB
1. Proposed lessee name and address for whom bonds issued: Fee:_____________ Rec. Date:________ Amt Rec.__________ Ck #______________

Guarantor for Bonds, if any:

Paying (Fiscal) Agent:

Underwriter, if any:

Attorney(s) who issued opinion: Bond Counsel:

Tenant Counsel:

City Attorney:

Underwriter's Counsel:

CTA-IRB (Rev. 7/08)

IRB Informational Statement Page 2 of 3

2.

Will an exemption of the property be requested? If exemption will be sought: a.

Yes_____

No_____

Provide the legal description of the property. (If legal description is lengthy, attach additional pages.) Provide the appraised valuation (not assessed) as listed by the county appraiser of property to be acquired, purchased, etc. as of the next preceding January 1.

b.

Land: Improvements: Equipment and Machinery 3.

$_______________________ $_______________________ $_______________________

Estimated TOTAL cost of the property: Land: Improvements: Equipment and Machinery $_______________________ $_______________________ $_______________________

4.

If facility financed is an addition or improvement to existing facility already financed by prior IRB issuance, supply following: Date prior I.R.B.s issued: If existing facility exempted, period of exemption: _______________________

_______________________

Court of Tax Appeals #: _______________________ 5. 6. IRB principal amount to be issued: Please provide the following: a. b. c. Itemized list of any payments in lieu of taxes. The amount of any service fee or charges with detailed description of services to be rendered by city for same. Detailed description of ultimate use of bond proceeds (e.g. acquisition of real estate, remodeling of physical plant) with the amount of IRB proceeds to be used for each purpose. _______________________

7.

What is the proposed date of issuance of these I.R.B.s? (Must be a least 7 days after receipt of preliminary filing with the Court of Tax Appeals.)

IRB Informational Statement Page 3 of 3

VERIFICATION

I, ________________________________, do solemnly swear or affirm that the information set forth herein is true and correct, to the best of my knowledge and belief. So help me God.

_____________________________________ Signature of Applicant _____________________________________ Printed Name and Title State of ____________________ County of __________________ ) )

This instrument was acknowledged before me on __________ by ______________________________.

Seal

_____________________________________ Signature of Notary Public

My appointment expires: ________________

___________________________________________________________________________________ Send this statement along with the filing fee of $250.00 to: Court of Tax Appeals Docking State Office Building 915 SW Harrison, Ste 451 Topeka, KS 66612-1505 __________________________________________________________________________________