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HomeMy WebLinkAbout19-25 CBK Land Development Confirming Real Property Tax Abatement Filed in Clerk's Office rITS [ 2U1J9 ick' , f�AF�r=�N�AH Ft?WLER CITY CLERK,SOUTH REND, IN CITY OF SOUTH BEND COMMUNITY INVEST AE \T Council Member Gavin Ferlic, Chairperson April 3,2019 Community Investment Committee South Bend Common Council 4th Floor, County City Building South Bend, IN 46601 RE: Real Property Tax Abatement Petition for: CBK Land Development,LLC Dear Council Member Ferlic: Please find attached the Department of Community Investment's report on a real property tax abatement petition for the above-referenced petitioner. Also attached is a copy of the petition, Statement of Benefits form, and supporting information. The project calls for extension of a distribution center as part of the company's planned increase in productive capacity at 5245 Dylan Drive,South Bend. The project cost is approximately$3,500,000. The report contains the Department's findings relative to the above petition. The project meets the qualifications for a (7) seven-year real property tax abatement and a representative from CBK Land Development, LLC will be available to meet with the Committee on Monday, April 8,2019. Should you or any of the other Council members have any questions concerning the report, or need additional information,please feel free to call me at 235-5823. Sincerely, Daniel :uckenmeyer Director Economic Resources&Business Development DANIEL J.BUCKENMEYER Ai.KEYNAAI I)RIIX)E PAMELA MEYER TIM CORCORAN BUSINESS DEVELOPMENT ENGAGEMENT&ECONOMIC EMPOWERMENT NEIGHBORHOOD DEVELOPMENT PLANNING&COMMUNITY RESOURCES EXCELLENCE ACCOUNTABILITY INNOVATION INCLUSION EMPOWERMENT 1400S County-City Building 227 W.Jefferson Blvd. South Bend,Indiana 46601 p 574.235.9371 www.southbendin.gov TAX ABATEMENT ENT REPOR T TO: South Bend Common Council FROM: Angelina Billo SUBJECT: Real Property Tax Abatement Petition For: CBK Land Development LLC DATE: April 1, 2019 On March 25,2019, a petition for real property tax abatement consideration for property located at 5245 Dylan Drive,South Bend,IN was filed with the City Clerk by CBK Land Development,LLC. Pursuant to Chapter 2,Article 6,Section 2-84.2 of the Municipal Code of the City of South Bend,this petition was referred to the Department of Community Investment for purposes of investigation and preparation of a report determining whether the area qualifies as an Economic Revitalization Area pursuant to I.C.6-1.1-12.1 and whether all zoning requirements have been met. The Department of Community Investment has reviewed the petition,investigated the area,and makes the following report. PROJECT SUMMARY • Chase Plastics, a leading North American full-service specialty engineering thermoplastics distributor serving plastic processors throughout North and Central America,is planning to expand its current 126,000 sq.ft. distribution center by an additional estimated 80,000 sq.ft. Business conditions have put operations at near capacity causing the need to expand and maximize the use of the previously purchased land.With this expansion,the company will add additional truck dock doors and increase its overall storage capacity by 65%. • The estimated project cost is $3.5millon. • Petitioner is qualified for a seven-year real property tax abatement. • The estimated amount of taxes phased-in for the seven-year abatement is $469,961. Estimated paid taxes paid for the seven-year term are$118,039. Chase Plastics is the only tenant leasing from the ownership entity of CBK Land Development,LLC. The ownership of these two entities are closely related.The company moved into the newly constructed facility in Ameriplex 80/90 area back in 2015.This location is exceptional for a distribution operation. Due to its proximity to the intersection of the Interstate 80/90 and US Highway 31, it allows Chase Plastics to transport goods in all directions in a very efficient manner. EMPLOYMENT IMPACT Per this petition,the company will have nineteen(19)full-time jobs with an annual payroll of$775,384 by the end of 2019.It is estimated that in ten years the business will create twelve(12)new,permanent full- time positions and zero (0)part-time positions with an annual payroll of$475,280. ABATEMENT QUALIFICATION 1. A review of the tax abatements previously granted finds that the Petitioner, CBK Land Development,LLC has been granted or associated with one previous tax abatement. Term/Type Resolution No. Date 10-year real property 4406-14 11/12/2014 2. The Area Plan Commission has reviewed the petition and finds the property to be properly zoned for the proposed project. 3. The Building Commission has reviewed the petition and finds no building permit was issued. 4. The property is located in the River West Development area. 5. A review of the Tax Abatement Ordinance No. 9394-03 finds that the petitioner meets the qualifications for a(7) seven-year real property tax abatement under section 2-75 Real Property Tax Abatement General Standards. grl oo 0o d' ror o 00 r `� 0 0p 0 O O lam�ppo 0 0 Y 0 00 N N P7 m m-N N N6; o O 0 0 0 0 0 0 0 0 0 0 0 0 888 N U) U) 0 0 } O Q 0N N N Co N NU) fV Ngi e'D O O O o o N0,1 0 0 0 U) W 000 !D 0 to 00 0 Co Po O O 0 O) 0 6 > O p m N N N N W m m m< U) N N e... 0 0 0 0 o U)0.n 0 0 0 0 '.- O O O CD 0 0 o O W y 0 0 W r O O - o N m N m m 0210 N U) N N • d en z g 1 0 N.r UN 0 N. Ofr o0 o �D r r 000 0 o z � ,,.m. m8L m m 00 om m 0O m m r a-N CO N V N J '' W Q.0 N N 0 0 Sc �D �0 f. O O 0 g 2 O P)Co U)m O C) C .L` k O) 9 000 D) Co_ Co 0 0 ~N OO b to NCp.v t- a)) CD E 3~ r • m CO. D N r r m m Q IP:iti Dmma tp Oa. 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CITY CLERK,SOUTH BEND,IN A RESOLUTION CONFIRMING THE ADOPTION OF A DECLARATORY RESOLUTION DESIGNATING CERTAIN AREAS WITHIN THE CITY OF SOUTH BEND, INDIANA, COMMONLY KNOWN AS 5245 Dylan Drive, South Bend, IN 46628 AS AN ECONOMIC REVITALIZATION AREA FOR PURPOSES OF A SEVEN (7) YEAR REAL PROPERTY TAX ABATEMENT FOR CBK Land Development, LLC WHEREAS, the Common Council of the City of South Bend, Indiana, has adopted a Declaratory Resolution designating certain areas within the City as Economic Revitalization Areas for the purpose of tax abatement consideration; and WHEREAS, a Declaratory Resolution designated the area commonly known as 5245 Dylan Drive, South Bend, Indiana, and which is more particularly described as follows: Lot 2 Portage Prairie Minor #5 16/17 NP#1787 03-19-2015 15/16 NP#1338 03-07-2014 and which has Key Numbers 025-1010-0169 to be designated as an Economic Revitalization Area; and WHEREAS, notice of the adoption of a Declaratory Resolution and the public hearing before the Council has been published pursuant to Indiana Code 6-1.1-12.1-2.5; and WHEREAS, the Council held a public hearing for the purposes of hearing all remonstrances and objections from interested persons; and WHEREAS, the Council has determined that the qualifications for an economic revitalization area have been met. NOW, THEREFORE, BE IT RESOLVED by the Common Council of the City of South Bend, Indiana, as follows: SECTION I. The Common Council hereby confirms its Declaratory Resolution designating the area described herein as an Economic Revitalization Area for the purposes of tax abatement. Such designation is for Real property tax abatement only and is limited to three (3) calendar years from the date of adoption of the Declaratory Resolution by the Common Council. SECTION II. The Common Council hereby determines that the property owner is qualified for and is granted Real property tax deduction for up to a period of seven (7) years as shown by the schedule outlined below as well as the attachment pursuant to Indiana Code 6-1.1-12.1-17 and further determines that the petition, the Memorandum of Agreement between the Petitioner and the City of South Bend, and the Statement of Benefits comply with Chapter 2, Article 6, of the Municipal Code of the City of South Bend and Indiana Code 6-1.1-12 et seq. Year 1 - 100% Year 2 - 95% Year 3 - 95% Year 4 - 90% Years - 85% Year 6 - 80% Year?-75% SECTION III. This Resolution shall be in full force and effect from and after its adoption by the Common Council and approved by the Mayor. Tim Scott, Council President South Bend Common Council Find in Ciel City of South Bend • — -- Petition for Incentives �y�e�':� ��`" c,a - ��` 2J19 Petition must Include a$250 filingr, , fee payable to the City Clerk's Office or online via the City's website of ��' 441 hrip;//southbendin.goe/government/content/tax aboiement before processing con be complete �• r t /LER General Information Project Name Project Numbq Ci I ' ' ,'1 legal name as registered with Secretary al CBK Land Development LLC',Real Property)Chase Plastic Services,Inc.(Personal Property) stn. Business structure Limited Liability Company/Corporation Company wetnlle www.cha seplastics.com Proposed Project Information Proposed prolect address 5245 Dylan Drive P.m rompanyname Chase Plastic Services,Inc. City,State.Zlp South Bend, IN 46628 Legal owner CBK Land Development Site acreage or acreage required 9.55 Acres Is the teal estate owned or Owned teased Square feet of facility 78,$80 sq. ft. addition If tensed by whom N/A Primary Contact Information Primary company contact name Robert Hoff T111e Business Process Manager Address of company contact 6467 Waldon Center Dr. PI1one 248-620-8302 City,State,Zip Clarkston, MI 48346 (moil bhoff@chaseplastics.com Senior Official Information Company cantor nmclal name Kevin Chase Title President address of company contest jib dinerentfrom Same as Above pho"e 248-620-2120 above) City, State, Sip 'Same as Above rte' kchase@chaseplastics.com Consultant Information/Agent Hired business ronsuitanlfagent name Majority 6ullders,Inc.-Rh,^.k Slagle Consultant release(y,Ml Yes Address 62900 U.S. 31 South Local economic development partners aowave((Y/Pat Yes City,Slate,Zip South Bend, IN 46614I rick@majoritybuilders.com Project Overview Brief description of yon: company,project,and why the Chase Plastics is a leading North Arnencan full-service specially engineenng thermoplastic distributor property is necessary for serving plastics processors throughout North and Central America.This application is submitted due to ,r/xxxvik growth Chase Plastics'desire to expand its current 126.000 sq.ft.distribution center by an additional estimated 80,000 sq.ft. After erecting our existing building in 2015,business conditions have put our operation at near capacity causing the Treed to expand and maximize the use of the previously purchased land.With this expansion, we will add additional(suck dock doers and increase our overall volume by 65%. CHASE PLASTIC SERVICES,INC.WILL CONTINUE TO BE THE TENANT OF THE BUILDING LEASING FROM THE BUILDING OWNER CBK LAND DEVELOPMENT LLC.THE OWNERSHIP OF THESE TWO ENTITIES ARE CLOSELY HFI D. Centficd Technology Park appropriate is the project In aTax Incremental Financing JTIF i area?If so.which? Gentry that the Building Permk has nor beenNumber of residential units treat+f_- issued IWNI Iordect If this is a petition for personal property tea abatement,has tire equipment been Installed investment Details Public Infrastructure needs foe. Has any 504 funding been What is the value of any equipment being purchased In Wha tis the value of any equipment Doing site of protect In dollars) received? Indiana for the protect? purchased from out of state for the dialect? Jdew Protect investments -- Calendar Year 2029 2020 2021 2022 2023 2024 2025 2026 land Acquisition Building Lease Payments Building Purchase Costs New Building Construction Existing Building Improvements S 2,500,000 CO New Machinery 8,Equipment $407,000.00 3 90,023.00 s 53,)20.00 9(0,000.00 $10,020.00 $35,000.00 S 10.000,00 j 3530-.,Oi! Sperlol Tooling/Retooling New Furniture/Fixtures $8,000.00 $2,500.00 $5,000.00 Maw Computer/1T Hardware 0 20.000,00 $23,000.00 $10,000 n0 5 10,000.00 New Software $5,000.00 i 9.,122:;.la ; I.i,tr;r cu 1 15,000 00 Onsite Rall Infrastructure On-site Fiber Infrastructure TOTAL I 14,000,000M $128,000 00 5 55,500.00 3 80,000.00 $10.000.00 3 40,000.00 $36,000.00 $30,000.00 Full-Time Permanent Indiana-Resident Positions by Calendar Year Calendar Year Jobs retained Total hourly Cumulative a ofnct NEW full time Hourly average wage,w/o Total training Total to be wage w/o permanent jobs created at project benefits or bonuses,of expenditure- trained-not fringe or cumulative net new fobs not cumulative bonuses cumulative 2019 18 19.62 1 2020 2 17.00 2021 2022 1 19.00 2023 0 17.50 2024 19.50 2025 1 20.00 2024 18.50 2027 0 2028 2 20.50 2029 1 19.00 2030 1 21.00 Provide hourly wage Information for new employees In the following positions. runtime Pan time Laborers 17.00 Technical Managerial Administrative 18.50 "Who will be the indlviauni responsible for coordinating with WorkOrte on Ferrol hoe Ones your company have an EEO hiring polky11 Yes Are you an EEO employer? 1Yes Please list the number of full time and part time minority and/or female employees for each of Please describe your commitment to the last three years: diversity and Inclusion by detailing your outreach and recruitment efforts for the last Year 2018 2018 2018 three years as Well as current policies. Full Time Part Time Full Time Part limo Full Time Part Time Black 5 5 5 Hispanic 1 I 1 Asian 1 Indian Female 4 3 3 Other Complete below for Real or Personal Property Tax Abatement only. Please sign for all requested incentives. Public Benefit Item: Information is required on both the construction companies and the companies which will provide materials purchased for this project. Please complete the table below with the appropriate information. If Qualify Earned Points Available Points (yes or Na) you qualify for the points,please enter the full amount of available points. 1 c9nSttuctlon Relatge(Contractorsl: 4 Employ Local Companies(75%) YES 20 20 3 Purchase Materials from Local Companies(75%) YES 20 20 _. Require Employees vs.Independent Contractors YES 19 19 Require Prevailing Wage(Davis Bacon) No 22 Require Health Benefits YES 22 22 ?. Require Pension Benefits VO 18 G. Maintain Affirmative Action Plan YES 20 20 Sub-total Construction Related: 101 141 2 Wag 8 Benefit Related(Owner): A. Pay Target Wage Levels YES 33 3j B. Provide Health Benefits YES 34 84 C. Provide Pension Benefits YES 29 29 0. Provide training YES 28 28 E. Provide Child Care NO F. Provide Transportation Assistance NO 14 G. Provide Employer Assisted Housing program NO 9 Sub-total Wage&Benefit Related: 124 152 3 Workforce Related: A. Create New Jobs YES 42 42 B. Retain Existing lobs YES 4 I 41 C. Maintain Affirmative Action Plan No 0 35(� 0. Provide Targeted Hiring Preference '`t o 34 Sub-total Workforce Related: 83 152 4 Support a Municlpai Facility: Support a SB Municipal Facility(donations to the A. coo,conservatory,museum,etc.) YES 84 84 Name of Facility Po(awalo� I Sub-total Municipal Facility: as 81 Sub-total from Above: fj 5' The undersigned owner(s)of real property,located within the City of South Bend,herby petition the Common Council of the City of South Bend for a real and/or personal property tax abatement consideration and pursuant to I.C.,6-1.1-12.1-1,et seq.,and South Bend Municipal Code Sec.2-76 et seq.,for this petition state the above. { 9 Submitted By: � �\ 7 Dattst 13/Zz/( For Staff Use Only Below This Line What Is the current assessed value? Real Property: 3 i(/",c e2 i v Personal Property: 3 y6) What Is the projected assessed value? Real Property: 3 Sri, Dili' Personal Property: --7-,-,7�{• poo / / J What is the tax key number for this project? 0, 5--I K�l5— — O/D _ /' a; What Is the six digit NAILS code? V7C/g ' I(C e & 44 - PP), /93 f(0(C 2� ,, t-W —,E,4)) Please attach a Google map and street view of the location. Please list the amount of real and personal property taxes Real Property Taxes: Personal Property Taxes: paid for the last five years when applicable. G ,,s1//,...,-. Year One J /3 56. L. 7 J q = c(7Js ' oZO/Y lld Year Two (9`b9S - 5 S( - n^i�r jr Year Three />/ /252 _ 5:7 A? (,9 2 �� oGV fJ (n / J �l ? p y /te Year Four ' Q _ G'il O q ��///�Ycar Five /5– ,---- /' J Please fill out the following Public Benefit SummaryInformation and add to total from above. (Y or NI Points Points Public Benefit Item: Project Related: 5 A. Redevelop a Site that has Special Needs 49 B. Develop Based on Local University Research 35 C. Achieve a Physical Element of a Plan 36 Sub-total Project Related: 120 6 Super Size Projects p (point values are cumulative): A. 100%to 199% 25 B. 200%to 299% Ery 68 C. 300%to 399% g 65 D. 400%and Over 52 Sub-total Super Size Projects: '.5 6 210 7 Pay for Municipal Infrastructure: A Pay for Oversizing or Upgrading 14 B. Pay for 26-50%of Extension Cost 26 C. Pay for 51-75%of Extension Cost 39 D. Pay for 76-100%of Extension Cost L� 52 Sub-total infrastructure Related: -(j� U 131 Total from Applicant Section: 3 )2. 539 Total from Staff Section: (5--Ci 461 ,�j �- Total Public Benefit Points: v , 1000 Filed in Clerk's Office C4\/: STATEMENT OF BENEFITSMAR 2 5 201920PAY20REAL ESTATE IMPROVEMENTS Slate Form 617n7(R6! 0-94) i i t;_Jfir,,{ RFORM SB-1/Real Property Prescribed by the Department of Local Government Finan � E1=idiMt CITY(`.t F..9t.:,< SOUTH IT.1 PF 'D IN PRIVACY NOTICE This statement is being completed for real property that qualifies under the f CITY. Coda check ono tithe).—'——• My Information concerning the cost Q Redevelopment or rehabilitationt of real estate improvements(IC 6-1.1-12,1-4) of thepre xny and splits nby Inn pard to individual employees by tion ❑Residentially distressed area(IC 6-1.1-12,1-4.1) pproperty owner is confidential oar INSTRUCTIONS: IC 6.1.1-121-5.1. 1. This statement must be submrlfed 10 the body designating the Economic Revitalization Aloa prior to the public hearing if the designating body requires InlomatIon from the applicant in making its decision about whether to designate.en Economic Revitalization Arse. Otherwise,this statement must he submitted to the designating body BEFORE the redevelopment or rehabilitation of real property for which the person wishes to claim a deduction. 2. The statement of benefits form must be submitted to the designating body and the area designated on economic revllalizatlon area before the inglel/on of the re.develepmenf or rehabilitation for which the person desires to claim a deduction. 3. To obtain a deduction,a Form 322/RE must be filed with the County Auditor before May IO In the year in which the addition to assessed valuation Is made or not later than thirty(30)days oiler the assessment notice Is mailed/o the properly owner if It was malted after Apra 10. A properly owner who failed fo file a deduction application within the prescribed deadline may lila an application between March 1 and May 10 of a subsequent yeah 4I. A property owner who files for the deduction must provide the County Auditor end designating body with a Form CF-1/Reel Property. The Form CF-1/Real Properly should be attached to the Form 322/RE when the deduction is first claimed and then updated annually for each year the deduction Is applicable. IC 6-1.1-12.1-5.1(b) 5. For a Form SB-I/Real Property that is approved atter June 30, 2013, the designating body is required to establish an abatement schedule for each deduction slowed. For a Form SB-1/Real Property that is approved prior fo July 1. 2013,the abatement schedule approved by the designating body remains in effect. iC 6-1.1-12.1-17 SECTION 1 TAXPAYER INFORMATION Name of taxpayer CBK Land Development, LLC Address et taxpayer(number and street.city stats.and ZIP code) — 5245 Dylan Drive South Bend, IN 46628 Name of contact person Telephone number E-moll address ( ) 248-620-7784 landrew@chaseplastics.com SECTION 2 LOCATION AND'DESCRIPTION OF PROPOSED PROJECT Name of designating body Resclutlon number CBK Land Development, LLC Location or propertyCounty DLGF taxing district number 5245 Dylan Drive, South Bend, IN 466281 St. Joseph Description of real property unprovements,redevelopment,or rehabilitation(use addeonel sheets If necessary) EnUmnled start data(month,day,year) May 2019 Project will consist of adding an approximate 80,000 sq.ft. to the existing 126,000 sq. ft.at Estimated completion dela(moMr,day,year) January 2020 SECTION 3 ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PROJECT Currant number Salaries Number retained Salaries Number additional Salaries 18 $847,000 18 $847,000 13 $520,000 SECTION 4 ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT I REAL ESTATE IMPROVEMENTS ! COST ASSESSED VALUE Current values $5,647,964 $3,465,000 Plus estimated values of proposed project !$3,500,000 I l Less values of any properly being replaced Is() l 1 Net estimated values upon comr!ellon of•rolect $9,147,964 SECTION 5 WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER Estimated solid waste converted(pounds) Estimated hazardous waste conversed(pounds) 1 • Other benefits l I 1 SECTION G TAXPAYER CERTIFICATION I heroby certify that the representations in this statement are true. Sigtiro of authorize cental Delo shred(month.day.year) 1 .V /f 9 Printed name of authorized represental a Titin ���Efz'r- t t�cc4 t„C s,fuss-�&.S < Page 1 of2 FOR USE OF THE DESIGNATING BODY We find that the applicant meets the general standards In the resolution adopted or to be adopted by this body. Said resolution,passed or to be passed Under IC 6-1.1-12.1,provides for the following limitations: A, The designated area has been limited to a period of time not to exceed calendar years*(see below). The date this designation expires Is B. The type of deduction that Is allowed in the designated area is limited to: 1.Redevelopment or rehabilitation of real estate Improvements ❑Yes ❑No 2.Residentially distressed areas ❑Yes ❑No C. The amount of the deduction applicable is limited to$ D, Other limitations or conditions(specify) E. Number of years allowed: ❑Year 1 C1 Year 2 ❑Year 3 ❑Year 4 ❑ Year 5 ('see below) ❑Year 6 ❑Year 7 ❑Year B ❑Year 9 ❑ Year 10 F. For a statement of benefits approved after June 30,2013,did this designating body adopt an abatement schedule per iC 6-1.1-12.1-17? ❑Yes ❑No If yes.attach a copy of the abatement schedule to this form. if no.the designating body Is required to establish an abatement schedule before the deduction can be determined. • We have also reviewed the Information contained in the statement of benefits and find that the estimates and expectations are reasonable and have determined that the totality of benefits le sufficient to Justify the deduction described above. Approved(signahIm and alio of authorized member of dnafgnafing body) Telephone number Dale aimed(month,day yoarl ( ) Printed name or authorized member of desfgnnling body Nemo of designatin0 body Attested by(sfpna(uro and title of attester) Printed name of attester •if the designating body limits the time period during which an area is an economic revitalization area,that limitation does not limit the length of lime a taxpayer Is entitled to receive a deduction to a number of years that is less than the number of years designated under IC 6-1.1-12.1-17. A. For residentially distressed areas where the Form SB-1/Real Property was approved prior to July 1,2013,the deductions established in iC 6-1.1-12.1.4.1 remain In effect.The deduction period may not exceed five(6)years. For a Form SB-I/Real Property that Is approved after June 30, 2013,the designating body Is required to establish an abatement schedule for each deduction allowed. The deduction parted may not exceed ten (10)years. (See IC 6-1.1-12.1-17 below.) B. For the redevelopment or rehabilitation of real property where the Form SB-1/Real Property was approved prior to July 1,2013,the abatement schedule approved by the designating body remains In effect.For a Form SB-1/Real Property that is approved after June 30,2013,the designating body is required to establish an abatement schedule for each deduction allowed.(See IC 6-1,1-12.1-17 below.) IC 6-1.1-12.1-17 Abatement schedules Sec.17.(a)A designating body may provide to a business that is established In or relocated to a revitalization area and that receives a deduction under section 4 or 4.5 of this chapter an abatement schedule based on the following factors: (1) The total amount of the taxpayer's Investment in real and personal property, (2) The number of new full-time equivalent Jobs created. (3) The average wage of the new employees compared to the state minimum wage. (4) The Infrastructure requirements for the taxpayer's investment. (b) This subsection applies to a statement of benefits approved alter June 30,2013. A designating body shall establish an abatement schedule for each deduction allowed under this chapter. Art abatement schedule must specify the percentage amount of the deduction for each year of the deduction. An abatement schedule may not exceed ten(10)years. (c) An abatement schedule approved for a particular taxpayer before July 1,2013,remains in effect until the abatement schedule expires under the terms of the resolution approving the taxpayer's statement of benefits. Page 2 of 2 VII t Ilk W s4 a J >- ! ‘01 tti J W , Q 11 74 > Ce a Y � a o L„ U) Z 0 2 < I i 4 � a"� J.7y�.pa SO _ c-•4 J LL Q j• -7.7 tr fid �-S �3 Z C OCU. � �Sorl C a_ 0.1 • C17 -1 L i rn F I- 4-4o 'n ri ci N ,Y On 0 U L. M et O n as .D N �t r. Q. N U 00 7 v+ Q 00 C ,_i a aoE s. 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