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                STATEMENT FOR DEDUCTION OF ASSESSED VALUATION                                                                        JANUARY 1, 20____ 
                (Investment Property Purchased by Manufacturers of Recycled  
                Coal Combustion Products)                                                                                                   FORM 
                State Form 52499 (R2 / 4-16)                                                                                                PP - CCP 
                Prescribed by the Department of Local Government Finance
 
FILING DATE:           Must be filed between January 1 and May 15 of the year the deduction is requested.  If a filing extension has been granted on a  
                       person’s personal property return, this form must be filed between January 1 and the extended due date. 
 
INSTRUCTIONS:          1. This form is to be filed with the auditor of the county in which the property is located (IC 6-1.1-44-6). 
                       2. This deduction is for manufacturers who use coal combustion by-products in the manufacture of components such as  
                          aggregates, fillers, or cementitious materials, individually or in combination, to produce masonry construction products, filter  
                          media and other products approved by the Indiana Center for Coal Technology Research, Energy Center at Discovery Park,  
                          Purdue University, 203 South Martin Jischke Drive, West Lafayette, Indiana 47907. 
                       3. Attach proof of purchase of the investment property and proof of installation date.  
 
A component is considered “recycled” if at least 15% (by weight) of the component is made from coal combustion products such as boiler slag, bottom 
ash, fly ash and scrubber sludge as defined in IC 6-1.1-44 
 
Name of taxpayer                                                                                                               Federal Identification number

Name under which business is conducted                                                                                         DLGF Taxing District name

Address where property is located (number and street, city, state, and ZIP code)                                               DLGF Taxing District number

Nature of business                                                                County                                       Township 

Deduction Claimed:                                                                                                              * PURCHASE HISTORY (eg. Tons) 
    IC 6-1.1-44-3(a)(2)(A)  New business                                                                                       Current year 
    IC 6-1.1-44-3(a)(2)(B)  Existing business expanding into recycled products                                                 Last year 
    IC 6-1.1-44-3(a)(2)(C)  Existing business and increasing purchase of coal combustion products by 10% over                  Twp (2) years previous 
      the greatest of the prior the three (3) years. Complete Purchase History to the right* and attach proof for prior years. Three (3) years previous 
 
                                                     CALCULATION OF DEDUCTION CLAIMED 
1.  Assessed value of the QUALIFIED INVESTMENT as reported in the first year (Depreciable                                      $ 
    Personal Property used in the manufacturing of the recycled components – attach list)   
2.  Apply percentage eligible for deduction                                                                                                 x .15 

3.  Assessed value eligible for deduction (15% of Line 1)                                                                      $ 
 
                                                           SIGNATURE AND VERIFICATION 
I (we) hereby certify that the property is qualified for the deduction claimed and the above statements are true, correct and complete. 
Signature of taxpayer                                                                                                          Date (month, day, year)

Printed name and title                                                            E-mail address                               Telephone number 
                                                                                                                               (       ) 
I acknowledge receipt of this deduction application. 
Printed name of auditor 

Signature of auditor                                                                                                           Date (month, day, year)

                                  RECEIPT FOR STATEMENT OF DEDUCTION OF ASSESSED VALUATION 
                                  Investment Property Purchased by Manufacturers of Recycled Coal Combustion Products 
Name of taxpayer                                                                                                               Key number 

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

Any person commits a level 6 felony if he (she) makes and subscribes a property tax return statement or document that he (she) does not believe is 
correct in every material respect pursuant to IC 6-1.1-37-3. 
 
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