Fillable Printable Compliance With Statement Of Benefits Personal Property
Fillable Printable Compliance With Statement Of Benefits Personal Property
Compliance With Statement Of Benefits Personal Property
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 PROPERTYSECTION 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 SALARIESSECTION 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 VALUESSECTION 4
R & D EQUIPMENT
COST
ASSESSED
VALUE
SECTION 5
AS ESTIMATED ON SB-1 ACTUAL
TAXPAYER CERTIFICATIONSECTION 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
MANUF ACTURING
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 (1) compliance (CF-1).
DLGF taxing district number
Resolution number
Page 1 of 2
Reset Form
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: (1) the property owner; (2) the County Auditor;
and (3) 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)
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