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PRIVACY NOTICE FORM CF-1 / PP
COMPLIANCE WITH STATEMENT OF BENEFITS This form contains confidential
information pursuant to
PERSONAL PROPERTY IC 6-1.1-35-9 and IC 6-1.1-12.1-5.6. 20___ Pay 20___
State Form 51765 (R7 / 12-22)
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, 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 form (CF-1).
SECTION 1 TAXPAYER INFORMATION
Name of Taxpayer County
Address of Taxpayer (number and street, city, state, and ZIP code) DLGF Taxing District Number
Name of Contact Person Telephone Number Email Address
( )
SECTION 2 LOCATION AND DESCRIPTION OF PROPERTY
Name of Designating Body Resolution Number Estimated State Date (month, day, year)
Location of Property Actual Start Date (month, day, year)
Description of new manufacturing equipment, new research and development equipment, new information technology equipment, or Estimated Completion Date (month, day, year)
new logistical distribution equipment to be acquired.
Actual Completion Date (month, day, year)
SECTION 3 EMPLOYEES AND SALARIES
EMPLOYEES AND SALARIES AS ESTIMATED ON SB-1 ACTUAL
Current Number of Employees
Salaries
Number of Employees Retained
Salaries
Number of Additional Employees
Salaries
SECTION 4 COST AND VALUES
MANUFACTURING RESEARCH & LOGISTICAL DISTRIBUTION IT EQUIPMENT
EQUIPMENT DEVELOPMENT EQUIPMENT EQUIPMENT
AS ESTIMATED ON SB-1 COST ASSESSED COST ASSESSED COST ASSESSED COST ASSESSED
VALUE VALUE VALUE VALUE
Values Before Project $ $ $ $ $ $ $ $
Plus: Values of Proposed Project $ $ $ $ $ $ $ $
Less: Values of Any Property Being Replaced $ $ $ $ $ $ $ $
Net Values Upon Completion of Project $ $ $ $ $ $ $ $
ACTUAL COST ASSESSED COST ASSESSED COST ASSESSED COST ASSESSED
VALUE VALUE VALUE VALUE
Values Before Project $ $ $ $ $ $ $ $
Plus: Values of Proposed Project $ $ $ $ $ $ $ $
Less: Values of Any Property Being Replaced $ $ $ $ $ $ $ $
Net Values Upon Completion of Project $ $ $ $ $ $ $ $
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
WASTE CONVERTED AND OTHER BENEFITS AS ESTIMATED ON SB-1 ACTUAL
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)
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