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                 STATEMENT FOR DEDUCTION FROM ASSESSED VALUATION                                                                                         FORM
                 BUILDING CONSTRUCTED OF COAL COMBUSTION PRODUCTS                                                                                       RE-CCP
                 State Form 52500 (R4 / 6-14)
                 Prescribed by the Department of Local Government Finance
FILING DATE:          For real property, form must be completed and signed by December 31 and filed or postmarked by the following January 5.
                      For mobile homes not assessed as real property, the form must be filed during the twelve (12) months before March 31 of the year for which 
                      the deduction is sought. (IC 6-1.1-12-35.5)
INSTRUCTIONS: 
1. This form is to be filed in duplicate with the auditor of the county in which the property is located. (IC 6-1.1-12-34.5)
2. The deduction is for qualified buildings designed and constructed to use materials whose dry weight is at least 60% coal combustion products.
3. Direct written request for Proof of Certification along with drawings illustrating improvements complete with dimensions, height and thickness of walls and 
 materials in addition to documents to verify work done, i.e., statements and bills from contractors builders and suppliers, to:  Purdue University - Office of 
 Center for Coal Technology Research, 500 Central Drive, West Lafayette, Indiana 47907-2022.
4. Attach a copy of the Certification of Qualifying Building obtained from the Center for Coal Technology Research.
  If unavailable, attach copy of request including supporting documents.
                                                                 CERTIFICATION STATEMENT
 STATE OF INDIANA, COUNTY OF ________________________________________________________________ ,  SS:
 I (We), __________________________________ certify that I (we) own the following described property and that the property is eligible for a deduction 
 to the assessed valuation under IC 6-1.1-12-34.5 as is hereby claimed.

                                                                 PROPERTY DESCRIPTION
 Taxing district (city, town, township)      DLGF taxing district number                                  Parcel or key number

 Address of property / legal description

 Address of owner (number and street, city, state, and ZIP code)

 I (we) hereby certify that the above statement is true, correct and complete:
 Signature of taxpayer                                                                                                      Date (month, day, year)

 Printed name and title                                                        E-mail address                               Telephone number
                                                                                                                            (            )

                                                                 FOR AUDITOR'S USE ONLY
 1. Assessed value of QUALIFIED BUILDING                                                                                    $
 2. Apply percentage eligible for deduction                                                                                               x .05
 3. Assessed value eligible for deduction. (5% of Line 1)                                                                   $                            0.00
 4. Deduction is applicable for 3 years beginning and carrying forward through pay                                          pay                         pay
 I acknowledge receipt of this deduction application.
 Signature of auditor                                                                                                       Date (month, day, year)

 Printed name of auditor 

 I hereby verify that the above statements are true and correct.
 Signature of assessing official                                                                                            Date (month, day, year)

 Printed name of assessing official                                            Title of assessing official

                                             RECEIPT FOR STATEMENT OF DEDUCTION OF ASSESSED VALUATION
                                             Buildings Constructed of Coal Combustion Products
 Name of owner                                                                                                              Parcel or key number

 Description of property in county                                                                                          Township

 Signature of auditor                                                                                                       Date filed (month, day, year)