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STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />State Form 61797 (R4 12 -13) <br />Prescribed by the Department of Local Government Finance <br />This statement is being completed for real property that qualities under the following <br />9 Redevelopment or rehabilitation of real estate improvements (IC 6- 1.1- 12.14) <br />❑ Residentially distressed area (IC 6- 1.142.1 -4.1) <br />I l �7 6�ep oLE in ^�sBp &saa p� rR1 :.. €'. <br />20_- PAY 20_ <br />RM S -11 Real Property <br />ISM CYNOTICE <br />castand ysfiftscindividual's <br />ry inform lion d confidential; the <br />baFmm d Ring is public recrord <br />1. 2.1.5 1(0) and (d). <br />INSTRUCTIONS. <br />1. This statement must be submitted to the body designating the Economic Revitalization Area prior to the public hearing tribe designating body requires <br />. information from the applicant in making its decision about whether to designate an Economic Revitalization Area. Otherwise, this stalemammust be <br />submitted to the designating body BEFORE the redevelopment orrehabiliitatton ofrea /properly for which the person wishes to claim a deduction. <br />Projects "planned a c ,Vted to atterJuly i. 1987. and areas designated after hily 1, 1987, require a STATEMENTOF BENEFITS. (IC 6-1.1 -12.1) <br />2. Approval of the designa6ngbody (City Council, Tovm Board, County Council, etc.) must be obtained priorto Initiation orthe redevelopment or <br />rehab9aaaon, BEFORE a deduction may be approved <br />3. 7b obtain a deduction, a Form 3221RE must be filed with the County Auddorbefore May 10 in the year in which the addition to assessed valuation Is <br />made or not later than thirty (30) days afterthe assessment notice is mailed to the property ownerif it was mailed afterApol 10. If the property owner <br />misses the May 10 deadline in the 1nrTal yearof 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- !)Real Property annually to the application to <br />show compliance with the Statement of Benefits. (IC 6- 1.1- 12.15.1(b) and IC 6i. 1- 12.1- 5.3g)J. <br />5. The schedules established under IC 6.1.1- 12.1.4(d) for rehabilitated property apply to any economic re vitalization areas designated after June 30, 2000, <br />unless an altemative deduction schedule is adopted by the designating body (IC 61.1- 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 />Code fieck one box) <br />iol*! 1:10 E <br />CITY CL4EPK, 60 H 8 <br />51:U11:1.11 <br />TAXPAYER INFORMATION <br />Nomeo(texpp V <br />yer / + <br />tNP T0Wt k'l aikt) <br />/ <br />e4 <br />ifn <br />Address of taxpayer tnumberand street. city. slat. anidZiPcocrat <br />Name ofcomacct person <br />A1�re ai ly'�y1 %Q 7F <br />Telephone number <br />(1" -)r'�j Z�'�''G 00-1) <br />E- nraileddrjs�s <br />yjaiIIFi/�jTPrA'P /N <br />SECTION 2 <br />Name of dasignatlnit body <br />LOCATION <br />D DESCRIPTION OF •.•. <br />RosoNton number <br />Location 01 property <br />1 W- Ala-it <br />14ed <br />Ceunty <br />(� leis ld <br />OLGF taxing diSida number <br />Descupbon of real property improvements, redevelopment. <br />or renaollilavon (use addiaaral shoats dnecessary <br />Esdmaled wart tlale (mcrkh. day year) <br />Estimated comget d-date(month, day. year) <br />Current number <br />Estimated solid waste converted (pounds) I Estimated hazardous waste converted (pounds) <br />0. eCTI <br />ecode <br />6r44-g' J UH <br />U clews 8oC' 1 M,l�tt. 1, Q <br />-,. -j <br />I hereby certify that the reResentat)pns in this statement are true. <br />day. year) <br />Page 1 of 2 <br />