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                 NOTICE OF CHANGE OF OWNERSHIP OR USE OF EXEMPT PROPERTY                                                                          FORM 136-CO/U
                 State Form 54173 (R4 / 11-15)                                                                                                    ASSESSMENT DATE
                 Prescribed by the Department of Local Government Finance.
                                                                                                                                                  January 1, 20 ______

INSTRUCTIONS:         1. Please type or print.
                      2.  This form is to be filed with the County Assessor where the property is located. Contact information for the County Assessor is 
                          available at http://www.in.gov/dlgf/2440.htm.
                      3.  An act occurring after the assessment date, including a change in use, value, character, or ownership of tangible property, or the age, 
                          disability, or income of any owner, buyer, or possessor of tangible property, does not affect the eligibility of the tangible property for an 
                          exemption for that assessment date. For the following assessment date, the person that obtained an exemption under IC 6-1.1-10 or 
                          the current owner of the property, as applicable, shall file a certified application in duplicate with the county assessor of the county in 
                          which the property that is the subject of the exemption is located.  In all cases, the person that obtained the exemption or the current 
                          owner of the property shall notify the county assessor for the county where the tangible property is located of the change in ownership 
                          or use in the year that the change occurs.        

 Check applicable box(es):                                           Change of Ownership                                             Change of Use

                                                                     OWNER INFORMATION
 Name of person giving notice                                                                           Telephone number
                                                                                                        (            )
 Mailing address (number and street, city, state, and ZIP code)

 Notice is being given by (check one):
                                       Current owner            Person or entity originally obtaining deduction
 Type of exemption (check one)
 Religious (IC 6-1.1-10-21)                                            Educational, literary, scientific, religious, or charitable purpose (IC 6-1.1-10-16)
 Fraternity or sorority property (IC 6-1.1-10-24)            Other_______________________________________________________________
 Date of ownership transfer or change in use (month, day, year)             Filing date of most recent Form 136 Exemption Application (month, day, year)

                                                                PROPERTY INFORMATION
 Parcel number                                                              Type of property (check one)
                                                                                                               Real                               Personal
 Location of property (real or personal property)

 Legal description (real property only)

 Description of Change in Use

                                                                          CERTIFICATION
 Signature of person giving notice                                                                      Date signed (month, day, year)

                                                 ASSESSOR’S CERTIFICATION OF RECEIPT OF NOTICE
 I hereby certify receipt of this notice of change of ownership or use of exempt property.
 Signature of County Assessor                                                                           Date signed (month, day, year)

DISTRIBUTION:  Original - County Assessor;      Copy - Person Giving Notice