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STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />State Form 51767 (R2 /1-07) <br />Prescribed by the Department of Local Government Finance <br />This statement is being completed for real property that qualifies under the following Indiana Code (check one box): <br />❑ Redevelopment or rehabilitation of real estate improvements (IC 6- 1.1- 12.1 -4) <br />❑ Eligible vacant building (IC 6- 1.1- 12.1 -4.8) <br />20_ PAY 20_ <br />FORM SB -1 / Real Property <br />INSTRUCTIONS: <br />1. This statement must be submitted to the body designating the Economic Revitalization 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 or rehabilitation of real property for which the person wishes to claim a deduction. <br />"Projects" planned or committed 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 rehabilitation, <br />BEFORE a deduction maybe approved. <br />3. To obtain a deduction, application Form 322 ERA/RE or Form 322 ERANBD, fNhichever is applicable, must be filed with the County Auditor by the later <br />of: (1) May 10; or (2) thirty (30) days after the notice of addition to assessed valuation or new assessment is mailed to the property owner at the address <br />shown on the records of the township assessor. <br />4. Property owners whose Statement of Benefits was approved after June 30, 1991, must attach a Form CF -1 /Real Property annually to the application to <br />show compliance with the Statement of Benefits. (IC 6-1.1- 12.1- 5.1(b) and IC <br />5. The schedules established under IC 6 -1.1- 12.1 -4(d) for rehabilitated property and under IC 6- 1.1- 12.1. 4.8(1) for vacant buildings apply to any statement <br />of benefits approved on or after July 1, 2000. The schedules effective prior to July 1, 2000, shall continue to apply to a statement of benefits filed before <br />July 1, 2000. <br />SECTION •• <br />Name of taxpayer <br />Address of taxpayer (numberand street city; state, and ZIP code) <br />Name of contact person Telephone number <br />E-mail address <br />SECTION 2 LOCATION AND DESCRIPTION OF PROPOSED PROJECT <br />Name of designating body <br />Resolution number <br />Location of property <br />County <br />DLGF taxing district number <br />Description of real property improvements, redevelopment, or rehabilitation (use additional sheets if necessary) <br />Estimated start date (month, day, year) <br />Estimated completion date (month, day, yea) <br />SECTION 3 ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PROJECT <br />Current number Salaries Number retained Salaries Number additional Salaries <br />SECTION 4 ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT <br />NOTE: Pursuant to IC 6 -1.1- 12.1 -5.1 (d) (2) the COST of the property REAL ESTATE IMPROVEMENTS <br />is confidential. COST ASSESSED VALUE <br />Current values <br />Plus estimated values of proposed project <br />Less values of any property being replaced <br />Net estimated values upon completion of project <br />SECTION • • AND OTHER BENEFITS PROMISED <br />BY THE TAXPAYER <br />Estimated solid waste converted (pounds) <br />Estimated hazardous waste converted (pounds) <br />Other benefits <br />Filed in Clark's ±Office <br />�v' "t 12 '115 <br />JOf191i~`a`1 .✓i <br />CITY C4ERK, (yt3Th BEND,1N <br />SECTION 6 TAXPAYER CERTIFICATION <br />I hereby certify that the representations in this statement are true. <br />Signature of authorized representative - <br />Title <br />Date signed (month, day, year) <br />Page 1 of 2 <br />