Application For Property Tax Exemption (Form 136) {9284}

APPLICATION FOR PROPERTY TAX EXEMPTION State Form 9284 (R10 / 11-15) FORM 136 Assessment date January 1, 20____ County Prescribed by Department of Local Government Finance INSTRUCTIONS: 1. Two copies of this form must be filed with the County Assessor of the county where the property is located. 2. This application must be filed on or before April 1 of the assessment year and must be re-filed every even year unless the exempt property is owned, occupied, and used for educational, literary, scientific, religious, or charitable purposes and continues to meet the requirements of IC 6-1.1-10-16 or IC 6-1.1-10-21, or is owned by a fraternity or sorority and continues to meet the requirements of IC 6-1.1-10-24. An application should be filed in any year in which an appeal to the Indiana Board of Tax Review or to a court for an exemption determination on the property is pending from any preceding year. 3. There is no filing fee. 4. All questions on page 1, 2, and 3 must be answered. If the question does not apply, write N/A in the space provided. FAILURE TO PROVIDE THE REQUESTED INFORMATION MAY RESULT IN A DENIAL OF THE APPLICATION FOR EXEMPTION. See page 5 for additional information. Type of filing: First-time filing Yes Yes Yes No No No Name of owner claiming exemption Address (number and street, city, state, and ZIP code) Telephone number Re-filing on same property Re-filing with changes E-mail address Describe these changes. ( ) LAND Legal Description $ Assessed Value 1. 2. 3. IMPROVEMENTS (BUILDINGS) Description of Improvements (Name or describe each building) $ $ $ Hereby petitions for exemption from taxation of the following described real estate and improvements and / or personal property: Assessed Value Parcel Number Personal property assessment $ Date of assessment January 1, 20 _______ Township / Taxing District located in DLGF taxing district number Key number Upon what uses or purpose do you base the claim for exemption? Charitable - pursuant to IC 6-1.1-10-16. Educational - pursuant to IC 6-1.1-10-16. Religious - pursuant to IC 6-1.1-10-16. Other - (cite the specific law(s) under which the exemption is claimed) What percentage do you claim should be exempt on the value of: Land and lots Improvements (buildings) 1. Personal property 2. 3. NOTE: The taxpayer must present evidence that the property qualifies for exemption under a SPECIFIC statute. Please indicate that the following documentation has been provided: Articles of incorporation or other organizational documents Bylaws Financial statements for the last three years: Balance sheets Summary of income and expenditure If "Other" box is checked above - the specific statute under which the exemption is claimed must be cited. FAILURE TO PROVIDE SUCH DOCUMENTATION MAY BE GROUNDS FOR A DENIAL OF THE EXEMPTION SOUGHT. CERTIFICATE Under the penalties of perjury, I hereby certify that the statements in the application and information sheet are true and correct to the best of my knowledge and belief, and are made for the purpose of having the property described hereon, or a part thereof, exempt from taxation. A person who signs an exemption application shall attest in writing and under penalties of perjury that, to the best of the person's knowledge and belief, a predominant part of the property claimed to be exempt is not being used or occupied in connection with a trade or business that is not substantially related to the exercise or performance of the organization's exempt purpose. Signature of authorized representative Date signed (month, day, year) Printed name of authorized representative Title Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com REQUIRED INFORMATION INSTRUCTIONS: Please state all information for the tax year in question. If you need additional space to answer any questions or wish to provide additional information, use space at bottom of reverse side. Attach separate sheet if necessary. I. GENERAL 1. Who owns the property? (Name, address, type of entity, and purpose for which entity was formed per articles of incorporation or similar documents) 2. Who occupies the property? (Name, address, type of entity, and purpose for which entity was formed per articles of incorporation or similar documents) 3. Who uses the property? (Name, address, type of entity, and purpose for which entity was formed per articles of incorporation or similar documents) 4. For how much land is the exemption claimed? (See IC 6-1.1-10-16(c) and (d), 6-1.1-10-20, 21, 22, and 26) 5. Describe all structures and state specifically the normal use of each room or area in each structure. (You may attach a diagram of the property and structures.) II. EXEMPT PURPOSE 1. State specifically the exempt purpose and activities for which the property is used. (If any publications about the exempt activity are available, please provide a copy.) 2. State how often such activities occur. 3. State specifically what rooms or areas are used for the exempt purpose and what such use is. (Be sure all rooms or areas are discussed.) 4. Who carries out the exempt activities for which the property is used? 4a. State the qualifications of such individual(s). 4b. State if such individual(s) are certified or licensed by an entity, who has issued such certificate or license, and the qualifications required to obtain such certificate or license. 4c. How many individuals or groups participate in the exempt activities? 5. State what written materials, if any, are used. 6. What standards, if any, must individuals or groups benefiting from the exempt activity meet prior to participation in such activities? 7. State if the taxpayer is supervised by any entity, group or individual. 7a. State the name of such entity. 7b. State the address of the entity. 7c. State the nature and purpose of such entity. III. OTHER INFORMATION 1. Are rooms or areas ever used by individuals or groups for purposes not related to the claimed exempt use? (If "No", skip to 2.) Yes No 1b. State specifically what rooms or areas are used by such individuals or groups. 1a. Name such individuals or groups. 1c. State specifically how often such individuals or groups use such rooms or areas. 2. Do those benefiting from the exempt activity ever use areas or rooms for activities not 2a. State who makes such use of rooms or areas. directly related to the activity of the taxpayer? (If "No", skip to 3.) Yes No 2b. State specifically what rooms or areas are so used. 2c. State specifically how often such