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2. IMPACT FEE WITHHOLDING
   USE THIS FORM TO: Apply to have impact fees that are associated with a construction project withheld.
4. Fees

   1. There is no fee for this application.
6. IMPORTANT NOTES
   The attached policy identifies the organizations and/or projects which are eligible to apply for a withholding of the collection of impact fees, and defines the circumstances in which the request may be considered by the City Commission. The Department of Planning & Conservation will assist in scheduling the application for review by the City Commission. The amount of fees withheld are determined based on the point system outlined in the attached policy. There is a maximum benefit allowance of $25,000 per calendar year for any eligible individual or organization.
8. Key Contacts:
   The Department of Planning & Conservation will guide your application from start to finish, engaging other City departments or agencies as needed.
10. One or More of the Following Criteria Must be Demonstrated in Order to be Eligible for Making Application to Withhold Impact Fee Collection:*

    1. The project provides affordable housing.
    2. The project supports the activities of a documented non-profit entity based in Nassau County which provides benefits to City residents (proof of non-profit status required).
    3. The project is of significance to the local economy (job creation, tax generation, economic stimulation).
    4. Homesteaded residential property owner who demonstrates household income which is at or below the local poverty level (prior year’s tax form required).
12. PROPERTY INFORMATION
    Property information can be found at the Nassau County Property Appraiser’s Website → Map Search
14. Site Address*
16. City*
17. State*
18. Zip*
20. Parcel ID #(s)*
22. Lot #*
23. Block #*
25. OWNER OF RECORD
    As recorded with the Nassau County Property Appraiser
27. First Name*
28. Last Name*
30. Company (if applicable)
32. Mailing Address*
34. City*
35. State*
36. Zip*
38. Telephone Number*
39. E-mail Address*
41. OWNER'S AGENT
    If an agent will be representing the owner, an Owner’s Authorization For Agent Representation form must be included
43. First Name
44. Last Name
46. Company (if applicable)
48. Mailing Address
50. City
51. State
52. Zip
54. Telephone Number
55. E-mail Address
57. PROJECT INFORMATION
59. Project Type*

    1. Residential

    1. Non-Residential
60. Heated Area
    sq. ft.
61. Floor Area
    sq. ft.
63. Impact Fee Total*
65. Requested Withholding*

    1. Full

    1. Partial
66. If partial, please indicate amount you wish to have withheld:
68. 1. The mission of your organization and/or its basic purpose:*
70. 2. The specific public good the proposed facility will provide to Fernandina Beach residents:*
72. 3. Describe the qualifying circumstances for this request (i.e. hardship or replacement of facilities serving the public which have been lost as a result of disaster and when the loss is not reimbursable from a third party):*
74. 4. Whether land development related impact fees have previously been withheld for this organization:*
76. 5. Public or private contributions that have been received for this project:*
78. If applicable, please submit a copy of the documentation of your organization’s IRS non-profit status or a copy of your personal income tax filing for the prior year.
80. Certification*

    1. By signing below, I certify that the information contained in this application is true and correct to the best of my knowledge at the time of the application.
    2. I acknowledge that I understand and have complied with all of the submittal requirements and procedures.
82. Applicant's First Name*
83. Applicant's Last Name*
85. Todays's Date*
    Todays's Date
86. Upload Supporting Documentation
88. Upload 2
89. Upload 3
90. Upload 4
91. Upload 5
93. 
95. DEPARTMENT OF PLANNING & CONSERVATION
    204 Ash Street | Fernandina Beach, Florida 32034 | 904 310-3480 | www.fbfl.us/planning
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit Submit and Print

* indicates a required field