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PRIVACY NOTICE This form contains information confidential pursuant to IC 6-1.1-35-9 and IC 6-1.1-12.1-5.6. COMPLIANCE WITH STATEMENT OF BENEFITS PERSONAL PROPERTY State Form 51765 (R4 / 11-16) Prescribed by the Department of Local Government Finance TAXPAYER INFORMATION SECTION 1 Name of taxpayer Address of taxpayer (number and street, city, state, and ZIP code) Name of contact person ( ) LOCATION AND DESCRIPTION OF PROPERTY SECTION 2 Name of designating body Location of property Description of new manufacturing equipment, or new research and development equipment, or new information technology equipment, or new logistical distribution equipment to be acquired. Estimated start date (month, day, year) Actual start date (month, day, year) Estimated completion date (month, day, year) Actual completion date (month, day, year) County 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 R & D EQUIPMENT COST ASSESSED VALUE SECTION 5 AS ESTIMATED ON SB-1 ACTUAL 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) NOTE: The COST of the property is confidential pursuant to IC 6-1.1-12.1-5.6(c). 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 AS ESTIMATED ON SB-1 COST ASSESSED VALUE MANUFACTURING EQUIPMENT COST ASSESSED VALUE COST ASSESSED VALUE COST ASSESSED VALUE COST ASSESSED VALUE IT EQUIPMENT COST ASSESSED VALUE COST ASSESSED VALUE FORM CF-1 / PP EMPLOYEES AND SALARIES WASTE CONVERTED AND OTHER BENEFITS Telephone number LOGIST DIST EQUIPMENT INSTRUCTIONS: 1. Property owners whose Statement of Benefits was approved must file this form with the local Designating Body to show the extent to which there has been compliance with the Statement of Benefits. (IC 6-1.1-12.1-5.6) 2. This form must be filed with the Form 103-ERA Schedule of Deduction from Assessed Value between January 1 and May 15 of each year, unless a filing extension under IC 6-1.1-3.7 has been granted. A person who obtains a filing extension must file between January 1 and the extended due date of each year. 3. With the approval of the designating body, compliance information for multiple projects may be consolidated on one compliance (CF-1). DLGF taxing district number Resolution number Page 1 of 2 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 6-1.1-12.1-5.9) 1. This page does not apply to a Statement of Benefits filed before July 1, 1991; that deduction may not be terminated for a failure to comply with the Statement of Benefits. 2. Within 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. 3. 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. If a notice is mailed to a property owner, a copy of the written notice will be sent to the County Assessor and the County Auditor. 4. Based on the information presented at the hearing, the designating body shall determine whether or not the property owner has made reasonable effort to substantially comply with the Statement of Benefits and whether any failure to substantially comply was caused by factors beyond the control of the property owner. 5. If the designating body determines that the property owner has NOT made reasonable effort to comply, then the designating body shall adopt a resolution terminating the deduction. The designating body shall immediately mail a certified copy of the resolution to: the property owner; the County Auditor; and the County Assessor. 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. AM PM HEARING RESULTS (to be completed after the hearing) Approved Denied (see instruction 5 above) Reasons for the determination (attach additional sheets if necessary) Signature of authorized member Attested by: Date signed (month, day, year) 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 clerk of 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. Designating body 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) Page 2 of 2