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DR-486 Section III R.12/96 Real Property Page 2 Complete this section only if purpose number 1 or 3 in Section I is checked. k:-k t � 3 Petition No. Property described in Section I is used as follows: ❑ Residential ❑ Apartment Building ❑ Duplex ❑ Hotel ❑ Store ❑ Office ❑ Shopping Center ❑ Agricultural ❑ Industrial ❑ Motel ❑ Other ❑ Vacant Did you purchase land and building? Total price$ Date purchased Total cost of building $ Cost'of land $ Cost of improvements after purchase$ Date Built Mortgage (if any) in amount of $ Date of Mortgage Balance Due$ Amount of Insurance$ Age of Building Is property rented or leased? ❑ Yes ❑ No If yes. Net Income$ Gross Income $ Is property agricultural? ❑ Yes ❑ No If yes. Type of agricultural use Total acreage Acreage under agricultural use Professional appraiser's report of value (if available) $ Section IV I am willing to submit any additional information pertinent to this petition. ❑ Yes ❑ No Have you discussed this assessment with the property appraiser prior to filing this petition? ❑ Yes ❑ No If"No",was a conference requested? ❑ Yes ❑ No State of Florida_ , nn , County of Before.me,the undersigned authority, personally appeared who in my presence subscribed the foregoing petition and who after having been duly sworn deposed and said that he or she is the owner of the property described in Section I of the foregoing petition;that the above and foregoing statements of matters,facts,values and any exhibits attached are true and correct. �i�rnn Qam, tem [Signature of Petitioner] Sworn to (or affirmed)and subscribed before me this �- day of �^— by .I aYx !&OL1�feZ [Name of Petitioner] NOTARY PLIUC•SLkYE OF FLORIDA Personally Known * Athena M, Adams OR Produced Identif'Qsation Commission#DD396207 Type of Identification Produced - Z. Expires; FEB, 14, 2009 �-y� t Z 0 304dr,Adandc Boadtng Co,,Inc, '��m---0. U�• '� �,,o....�,--P Print, Type or Stamp Commissioned Name of Notary Signature of Notary Receipt I hereby certify that the foregoing pet' ion to the Value Adjustment Board was filed with the undersigned as the clerk of the governing body of this county on the day of Vl_/%3uA-G l,_ -2_ (a.m., p.m.) and the signing and delivery of a copy by me to the petitioner constitutes a receipt of the same, Iffurther certif that a copy of the foregoing petition was furnished by me to the property appraiser of this county on the 2� day of jA�C3,� l,__ , -?mss ct ��- County Clerk White - clerk's copy Yellow- appraiser copy Pink- petitioner copy