SIGNED STATEMENT OF PRIMARY RESIDENCE

Pursuant to Section 59-2-103 UCA

To: Daggett County, State of Utah

Attn: Lesa Asay, Assessor
PO Box 387
95 North 1st West
Manila, UT 84046

I understand that pursuant to Utah Code Section 59-2-309 (2)

any misrepresentation on this statement subjects the Owner to severe penalties

I am the owner of the following described property: Account No. ____________________________________________

Name: __James R. Fariello________________________ Parcel No. 02-0044-0009/T-A-009
Property Address:_131 South Taylor Flat ____[Plat A Lot 9 Taylor Flat Subdivision]__________________________
City: __Brown's Park__________________ State: ___Utah____________ Zip:__84023______
Mailing Address: __2021 Jessup Street __________________________________________
City: __Brighton____________________________ State: __Colorado__ Zip: ___80601________

 Please check and sign one:

The above described property is my permanent, full time residence and I have no other permanent residence either in the
State of Utah or any other state or country. I will occupy this property at least 183 consecutive days per calendar year. Date of
Occupancy:____________________________
Owner’s Signature: ________________________________________ Date Signed:__________


The above described property is NOT my Primary Residence. I do not have a long term
lease or renter. I do not qualify for any Primary Residence Exemption.
Owner’s Signature: ________________________________________
Date Signed: ___________________________________

As the owner, I am renting/leasing the above described property on a year round basis to the tenant/ family member named
below. Tenants do not have another permanent full-time residence in any state or province. They will occupy this property at
least 183 consecutive days per calendar year.
Lease start date: ___________________ **A copy of the lease must be included with this form**
Name of Tenant:_______________________________________________________________
Mailing Address: _______________________________________________________________
City:______________________________ State:_______________ Zip:___________________
Owner’s Signature: ________________________________________ Date Signed:__________

Dated this _______ day of _____________, ____________.

By: __________________________________________________________________________
Print Name: _James R. Fariello__
Address: _2021 Jessup Street in Brighton, Adams County, Colorado 80601_

SUBSCRIBED, SWORN TO, AND ACKNOWLEDGED before me in _Adams _ County, State of Colorado, this __ day of ________,
2017_.
_______________________________________________________________________
Notary Public

Submission of this application and statement authorizes the Assessor and/or staff to request or
collect information sufficient to verify Primary Residence Status