STATEMENT OF BENEFITS REAL ESTATE IMPROVEMENTS 20____ PAY 20____ FORM SB-1 / Real Property State Form 51767 (R2 / 1-07) Prescribed by the Department of Local Government Finance This statement is being completed for real property that qualifies under the following Indiana Code (check one box): Redevelopment or rehabilitation of real estate improvements (IC 6-1.1-12.1-4) Eligible vacant building (IC 6-1.1-12.1-4.8) INSTRUCTIONS: 1. This statement must be submitted to the body designating the Economic Revitalization Area prior to the public hearing if the designating body requires information from the applicant in making its decision about whether to designate an Economic Revitalization Area. Otherwise this statement must be submitted to the designating body BEFORE the redevelopment or rehabilitation of real property for which the person wishes to claim a deduction. "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) 2. Approval of the designating body (City Council, Town Board, County Council, etc.) must be obtained prior to initiation of the redevelopment or rehabilitation, BEFORE a deduction may be approved. 3. To obtain a deduction, application Form 322 ERA/RE or Form 322 ERA/VBD, Whichever is applicable, must be filed with the County Auditor by the later 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 shown on the records of the township assessor. 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 show compliance with the Statement of Benefits. [IC 6-1.1-12.1-5.1(b) and IC 6-1.1-12.1-5.3(j)] 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 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 July 1, 2000. SECTION 1 TAXPAYER INFORMATION Name of taxpayer Address of taxpayer (number and street, city, state, and ZIP code) Name of contact person E-mail address T elephone number ( SECTION 2 ) LOCATION AND DESCRIPTION OF PROPOSED PROJECT Name of designating body Resolution number Location of property County DLGF taxing district number Description of real property improvements, redevelopment, or rehabilitation (use additional sheets if necessary) Estimated start date (month, day, year) Estimated completion date (month, day, year) SECTION 3 Current number ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PROJECT Salaries SECTION 4 Number retained Salaries Number additional Salaries ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT REAL ESTATE IMPROVEMENTS COST ASSESSED VALUE NOTE: Pursuant to IC 6-1.1-12.1-5.1 (d) (2) the COST of the property is confidential. Current values Plus estimated values of proposed project Less values of any property being replaced Net estimated values upon completion of project WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER SECTION 5 Estimated solid waste converted (pounds) ________________________ Estimated hazardous waste converted (pounds) ___________________ Other benefits SECTION 6 TAXPAYER CERTIFICATION I hereby certify that the representations in this statement are true. Signature of authorized representative Title Page 1 of 2 Date signed (month, day, year) American LegalNet, Inc. www.FormsWorkflow.com FOR USE OF THE DESIGNATING BODY We have reviewed our prior actions relating to the designation of this Economic Revitalization Area and find that the applicant meets the general standards adopted in the resolution previously approved by this body. Said resolution, 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 2. Residentially distressed areas 3. Occupancy of a vacant building Yes Yes Yes No No No C. The amount of the deduction applicable is limited to $ __________________. D. Other limitations or conditions (specify)__________________________________________________________________________ E. The deduction is allowed for ______________________________ years* (see below). 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 is sufficient to justify the deduction described above. Approved (signature and title of authorized member of designating body) Telephone number ( Attested by (signature and title of attester) Date signed (month, day, year) ) Designated body * If the designating body limits the time period during which an area is an economic revitalization area, it does not limit the length of time a taxpayer is entitled to receive a deduction to a number of years designated under IC 6-1.12-12.1-4. A. For residentially distressed areas, the deduction period may not exceed five (5) years. B. For redevelopment and rehabilitation or real estate improvements: 1. If the Economic Revitalization Area was designated prior to July 1, 2000, the deduction period is limited to three (3), six (6), or ten (10) years. 2. If the Economic Revitalization Area was designated after June 20, 2000, the deduction period may not exceed ten (10) years. C. For vacant buildings, the deduction period may not exceed two (2) years. 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