APPLICATION FOR DEDUCTION FROM ASSESSED VALUATION OF REHABILITATED PROPERTY FORM 322A State Form 49567 (R4 / 7-08) Prescribed by the Department of Local Government Finance BUILDINGS OR STRUCTURES ONLY, ERECTED AT LEAST 50 YEARS PRIOR TO THIS APPLICATION County Township DLGF taxing district number The undersigned owner hereby applies to the County Auditor, pursuant to IC 6-1.1-12-22 through IC 6-1.1-12-24, for a deduction from the increase in assessed valuation resulting from rehabilitation of the following described property: Address of property (number and street or rural route) City Year building or structure originally erected Type of dwelling: Date of rehabilitation (month, day, year) Cost of rehabilitation Kind of rehabilitation: Single family dwelling Other ZIP code State Significant repairs Improvements Replacements LEGAL DESCRIPTION AS FOUND ON TAX DUPLICATE Section Township Lot number Range Addition Block number (IMPROVEMENTS ONLY) ASSESSMENT AFTER REHABILITATION (IMPROVEMENTS ONLY) ASSESSMENT (at 100% of TTV) PRIOR TO REHABILITATION Key or parcel number INCREASE DUE TO REHABILITATION DEDUCTION ON ASSESSMENT CLAIMED Application must be filed in person or by mail with the County Auditor prior to May 10 in the year in which Addition to Assessed Valuation is made OR not later than 30 days after the date of mailing of assessment notice by assessor, if such notice is not given prior to April 10. [IC 6-1.1-12-24 (a) and (b)] I hereby certify that the representations on this application are true. Signature of owner Printed name of owner (print or type) Address (number and street) City, state, and ZIP code VERIFICATION BY ASSESSING OFFICIAL Date (month, day, year) REDUCTION CALCULATION BY AUDITOR 1. Type of structure 1. Amount of INCREASE attributed to rehabilitation (Same as #8 on left) 2. Date erected (month, day, year) 2. 50% of #1 above 3. Date rehabilitated (month, day, year) 3. Maximum annual deduction (For single family dwellings - taxes due and payable prior to 1/1/05 $60,000; after 1/1/05 $124,800. For other structures - $300,000.) 4. Date reassessed (month, day, year) 5. Date taxpayer notified of increase in assessed valuation (month, day, year) 4. Annual deduction (Lesser of #2 or #3) 6. Assessed valuation of improvements AFTER rehabilitation 5. Date deduction approved (month, day, year) 7. Assessed valuation at 100% of TTV of improvements PRIOR TO rehabilitation 6. First year of deduction (Year in which taxes on rehabilitated portion of property became payable.) 8. Amount of INCREASE attributed to rehabilitation 9. Date verified (month, day, year) 7. Fifth year of deduction NOTE: Owner must have paid at least $10,000 for the rehabilitation. General reassessment during the deduction period does not affect the amount of the deduction. (IC 6-1.1-12-23) Signature of assessing official (or trustee) Signature of county auditor American LegalNet, Inc. www.FormsWorkflow.com