COMPLIANCE WITH STATEMENT OF BENEFITS REAL ESTATE IMPROVEMENTS 20____ PAY 20____ FORM CF-1 / Real Property State Form 51766 (R2 / 1-07) Prescribed by the Department of Local Government Finance PRIVACY NOTICE 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) The cost and any specific individual’s salary information is confidential; the balance of the filing is public record per IC 6-1.1-12.1-5.1 (c) and (d). INSTRUCTIONS: 1. This form does not apply to property located in a residentially distressed area. (IC 6-1.1-12.1-2 (b)) 2. Property owners must file this form with the County Auditor and the Designating Body for their review regarding the compliance of the project with the Statement of Benefits (SB-1 / Real Property). 3. This form must accompany the initial deduction application that is filed with the County Auditor. 4. Property owners whose Statement of Benefits was approved after June 30, 1991, must file an updated form with the County Auditor and the local Designating Body to show the extent to which there has been compliance with the Statement of Benefits. (IC 6-1.1-12.1-5.1) 5. The updated form must be filed annually by May 15, or by the due date for the real property owner’s personal property return that is filed in the township where the project is located, whichever is later. (IC 6-1.1-12.1-5.1 (b)) 6. With the approval of the Designating Body, compliance information for multiple projects may be consolidated on one (1) compliance form (CF-1 / Real Property). SECTION 1 TAXPAYER INFORMATION Name of taxpayer Address of taxpayer (number and street, city, state, and ZIP code) T elephone number Name of contact person SECTION 2 ( ) LOCATION AND DESCRIPTION OF PROPERTY Name of designating body Resolution number County Location of property DLGF taxing district number Estimated starting date (month, day, year) Description of real property improvements: Estimated completion date (month, day, year) SECTION 3 EMPLOYEES AND SALARIES EMPLOYEES AND SALARIES Current number of employees Salaries Number of employees retained Salaries Number of additional employees Salaries SECTION 4 AS ESTIMATED ON SB-1 ACTUAL COST AND VALUES REAL ESTATE IMPROVEMENTS COST AND VALUES AS ESTIMATED ON SB-1 COST ASSESSED VALUE Values before project Plus: Values of proposed project Less: Values of any property being replaced Net values upon completion of project ASSESSED VALUE COST ACTUAL Values before project Plus: Values of proposed project Less: Values of any property being replaced Net values upon completion of project SECTION 5 WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER WASTE CONVERTED AND OTHER BENEFITS Amount of solid waste converted Amount of hazardous waste converted Other benefits: SECTION 6 AS ESTIMATED ON SB-1 ACTUAL TAXPAYER CERTIFICATION I hereby certify that the representations in this statement are true. Signature of authorized representative Title Date signed (month, day, year) 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 6-1.1-12-5.1) 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. A copy of the notice will be sent to 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. 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 and (2) the County Auditor. 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 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) 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 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. American LegalNet, Inc. www.FormsWorkflow.com