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PRIVACY NOTICE The cost and any specific individual’s salary information is confidential; the balance of the filing is public record per IC 6-1.1-12.1-5.1 and PAY FORM CF-1 / Real Property COMPLIANCE WITH STATEMENT OF BENEFITS REAL ESTATE IMPROVEMENTS State Form 51766 (R3 / 2-13) Prescribed by the Department of Local Government Finance TAXPAYER INFORMATION SECTION 1 LOCATION AND DESCRIPTION OF PROPERTY SECTION 2 EMPLOYEES AND SALARIES SECTION 3 AS ESTIMATED ON SB-1 ACTUAL Current number of employees Number of employees retained Number of additional employees Salaries Salaries Salaries ACTUAL COST AND VALUES SECTION 4 SECTION 5 TAXPAYER CERTIFICATION SECTION 6 I hereby certify that the representations in this statement are true. Signature of authorized representative Title Date signed (month, day, year) Amount of solid waste converted Amount of hazardous waste converted Other benefits: WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER Values before project Plus: Values of proposed project Less: Values of any property being replaced Net values upon completion of project Plus: Values of proposed project Less: Values of any property being replaced Net values upon completion of project Values before project COST COST ASSESSED VALUE AS ESTIMATED ON SB-1 INSTRUCTIONS: 1. This form does not apply to property located in a residentially distressed area or any deduction for which the Statement of Benefits was approved before July 1, 1991. 2. Property owners must file this form with the county auditor and the designating body for their review regarding the compliance of the project with the Statement of Benefits (Form SB-1/Real Property). 3. This form must accompany the initial deduction application (Form 322/RE) that is filed with the county auditor. 4. This form must also be updated each year in which the deduction is applicable. It is filed with the county auditor and the designating body before May 15, or by the due date of the real property owner’s personal property return that is filed in the township where the property is located. (IC 6-1.1-12.1-5.1(b)) 5. With the approval of the designating body, compliance information for multiple projects may be consolidated on one compliance form (Form CF-1/Real Property). EMPLOYEES AND SALARIES REAL ESTATE IMPROVEMENTS COST AND VALUES AS ESTIMATED ON SB-1 ACTUAL WASTE CONVERTED AND OTHER BENEFITS ( ) Name of taxpayer Address of taxpayer (number and street, city, state, and ZIP code) Name of contact person County DLGF taxing district number Telephone number Name of designating body Location of property Description of real property improvements Resolution number Estimated start date (month, day, year) Actual start date (month, day, year) Estimated completion date (month, day, year) Actual completion date (month, day, year) Page 1 of 2 ASSESSED VALUE Reset Form ---PAGE BREAK--- OPTIONAL: FOR USE BY A DESIGNATING BODY WHO ELECTS TO REVIEW THE COMPLIANCE WITH STATEMENT OF BENEFITS (FORM CF-1) THAT WAS APPROVED AFTER JUNE 30, 1991 INSTRUCTIONS: (IC 6-1.1-12.1-5.1 and IC 6-1.1-12.1-5.9) Not later than forty-five (45) days after receipt of this form, the designating body may determine whether or not the property owner has substantially complied with the Statement of Benefits (Form SB-1/Real Property). If the property owner is found NOT to be in substantial compliance, the designating body shall send the property owner written notice. The notice must include the reasons for the determination and the date, time and place of a hearing to be conducted by the designating body. The date of this hearing may not be more than thirty (30) days after the date this notice is mailed. A copy of the notice may be sent to the county auditor and the county assessor. Based on the information presented at the hearing, the designating body shall determine whether or not the property owner has made reasonable efforts to substantially comply with the Statement of Benefits (Form SB-1/Real Property) and whether any failure to substantially comply was caused by factors beyond the control of the property owner. If the designating body determines that the property owner has NOT made reasonable efforts to comply, then the designating body shall adopt a resolution terminating the property owner’s deduction. If the designating body adopts such a resolution, the deduction does not apply to the next installment of property taxes owed by the property owner or to any subsequent installment of property taxes. The designating body shall immediately mail a certified copy of the resolution to: the property owner; the county auditor; and the county assessor. 1. 2. 3. 4. We have reviewed the CF-1 and find that: the property owner IS in substantial compliance the property owner IS NOT in substantial compliance other (specify) Reasons for the determination (attach additional sheets if necessary) If the property owner is found not to be in substantial compliance, the property owner shall receive the opportunity for a hearing. The following date and time has been set aside for the purpose of considering compliance. (Hearing must be held within thirty (30) days of the date of mailing of this notice.) AM PM HEARING RESULTS (to be completed after the hearing) Approved Denied (see instruction 4 above) Reasons for the determination (attach additional sheets if necessary) APPEAL RIGHTS [IC 6-1.1-12.1-5.9(e)] A property owner whose deduction is denied by the designating body may appeal the designating body’s decision by filing a complaint in the office of the Circuit or Superior Court together with a bond conditioned to pay the costs of the appeal if the appeal is determined against the property owner. Page 2 of 2 Signature of authorized member Attested by: Designating body Date signed (month, day, year) Time of hearing Date of hearing (month, day, year) Location of hearing Signature of authorized member Attested by: Designating body Date signed (month, day, year)