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i <br /> STATEMENT OF BENEFITS 2 PAY 20 <br /> REAL ESTATE IMPROVEMENTS <br /> State Form 51767(R4 12-13) LF:OR�M�SBA I Real Property <br /> Prescribed by the Departmeni of Local Government Finance <br /> PRIVACY NOTICE <br /> This statement is being completed for real property that qualities under the following Indiana Code(check one box); The cost and any spedfc indhddual's <br /> ❑ Redevelopment or rehabilitation of real estate improvements(IC 6.1.1-12.1-4) salary informal on Is confidential;the <br /> balance of the riling is public record <br /> ❑ Residentially distressed area(IC 6-1.1-12.1.4.1) per IC 6-1.1-12 1.5A(c)and(d). <br /> INSTRUCTIONS; <br /> 1. This statement must be submitted to the body designating the Economic Revitafrzation Area prior to the public hearing if the designating body requires <br /> information from the applicant in making its decision about whether to designate an Economic Revitalization Area. Otherwise,this statement must be <br /> submitted to the designating body BEFORE'the redevelopment orrehabliketion of rea/property for which the person wishes to claim a deduction, <br /> "Projects"pfannad orcommitted to after July 1, 1987,and areas designated after July 1, 1987,require a STATEMENT OF BENEFITS. (IC 6-1.1-12.1) <br /> 2. Approval of the designating body(City Council, Town Board,County Council,etc.)must be obtained prior to initiation of the redevelopment or <br /> rehabilitation,BEFORE a deduction may be approved. <br /> 3. To obtain a deduction,a Form 3221RE must be filed with the Cou*Auditor before May 10 in the year in which the addition to assessed valuation is <br /> made or not later than thirty(30)days after the assessment notice is mailed to the property owner if it was mailed after April 10. if the property owner <br /> misses the May 10 deadfrne in the initial year of occupation,he can apply between March 1 and May 10 of a subsequent year. <br /> 4, Property owners whose Statement of Benefits was approved after June 30, 1991,must attach a Form CF-11'Real Property annualty to the application to <br /> show compliance with the Statement of Benefits. 11C 6 1.i-12,1-5.1(b)and iC 6-1,1-12.1-5.30)1 <br /> 5. The schedules established under IC fi 1.1-121-4(d)for rehabilitated property apply to any economic revitalization areas designated after June 30,2000, <br /> unless an alternative deduction schedule is adopted by the designating body(1C 6-1.1-12.1-17). The schedules effective prior to July 1,2000,shall <br /> continue to apply to economic revitalization areas designated before July 1,2000. <br /> SECTION • <br /> Name of xp(ayert � (� <br /> G tJ• L ic e- 1 `��� . W i� <br /> Address of taxpayer(number and street,,city,state and ZIP code) _((\\ A a <br /> S7iGeo Name of contact person Telephone number E-mail address <br /> Name of desjgnatirry Oody <br /> Resotulbn number <br /> Location of prop- County DLGF taxing district number <br /> Description of real property improvements.redevelopment of rehabiti fuse additional sheets if necess -- Estunaled stag date(month,day.year) <br /> �owrfrAla-1;A>: f 3,Sao S 5a°1• ;(te-E )iqs(4m t <br /> Estimated completion date(month,day.Sear! <br /> SECTION 3 ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PRO.IECT <br /> Current n S lades N uMW retained iftloi6es St Number add liorel selarielf <br /> (. 35,x-tf(fCleo tp 3,ree� _IIDeel 1-S 3S^ i)Olt�oa <br /> REAL ESTATE IMPROVEMENTS <br /> I <br /> COST ASSESSED VALUE <br /> Current values *km D i <br /> Plus estimated values of proposed project / voo <br /> Less values of any property being replaced <br /> Net estimaled values upon completion of pr act <br /> SECTION • .AND• • r BY THE TAXPAYER <br /> Estimated solid waste converted(pounds) Estimated hazardors waste converted(pounds) <br /> Other benefits <br /> SECTION • <br /> I hereby cert ify that the representations in this statement are true. <br /> Signature of authorized representat ve Title <br /> � ♦1 yeaj <br /> W`�� Page 1 of 2 <br />