Compliance With Statement Of Benefits Personal Property (Form CF-1 PP) {51765}

COMPLIANCE WITH STATEMENT OF BENEFITS PERSONAL PROPERTY State Form 51765 (R4 / 11-16) FORM CF-1 / PP PRIVACY NOTICE This form contains information confidential pursuant to IC 6-1.1-35-9 and IC 6-1.1-12.1-5.6. Prescribed by the Department of Local Government Finance 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). TAXPAYER INFORMATION County SECTION 1 Name of taxpayer Address of taxpayer (number and street, city, state, and ZIP code) DLGF taxing district number Telephone number Name of contact person ( SECTION 2 Name of designating body ) LOCATION AND DESCRIPTION OF PROPERTY Resolution number Estimated start date (month, day, year) Location of property Actual start date (month, day, year) 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 completion date (month, day, year) Actual completion date (month, day, year) SECTION 3 Current number of employees Salaries Number of employees retained Salaries Number of additional employees Salaries SECTION 4 EMPLOYEES AND SALARIES EMPLOYEES AND SALARIES AS ESTIMATED ON SB-1 ACTUAL COST AND VALUES MANUFACTURING EQUIPMENT R & D EQUIPMENT COST ASSESSED VALUE LOGIST DIST EQUIPMENT COST ASSESSED VALUE IT EQUIPMENT COST ASSESSED VALUE AS ESTIMATED ON SB-1 Values before project Plus: Values of proposed project Less: Values of any property being replaced Net values upon completion of project ACTUAL Values before project Plus: Values of proposed project Less: Values of any property being replaced Net values upon completion of project COST ASSESSED VALUE COST ASSESSED VALUE COST ASSESSED VALUE COST ASSESSED VALUE COST ASSESSED VALUE NOTE: The COST of the property is confidential pursuant to IC 6-1.1-12.1-5.6(c). SECTION 5 WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER AS ESTIMATED ON SB-1 ACTUAL WASTE CONVERTED AND OTHER BENEFITS Amount of solid waste converted Amount of hazardous waste converted Other benefits: SECTION 6 TAXPAYER CERTIFICATION I hereby certify that the representations in this statement are true. Signature of authorized representative Title Date signed (month, day, year) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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) Signature of authorized member Date signed (month, day, year) Attested by: Designating body 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. Time of hearing AM PM Date of hearing (month, day, year) Location of hearing HEARING RESULTS (to be completed after the hearing) Approved Reasons for the determination (attach additional sheets if necessary) Denied (see instruction 5 above) Signature of authorized member Date signed (month, day, year) Attested by: Designating body 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. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com