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PRIVACY NOTICE
STATEMENT OF BENEFITS Any information concerning the cost of the FORM
UTILITY DISTRIBUTABLE PROPERTY property and specific salaries paid to CF – 1 / UD
State Form 52448 (R4 / 3-23) individual employees by the property
Prescribed by the Department of Local Government Finance owner is confidential per IC 6-1.1-12.1-5.1.
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 UD-ERA between January 1 and May 15 of each year 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/UD).
SECTION 1 TAXPAYER INFORMATION
Name of Taxpayer Name of Contact Person
Address of Taxpayer (number and street, city, state and ZIP code) Email Address of Contact Person
County Telephone Number Fax Number
( ) ( )
SECTION 2 LOCATION AND DESCRIPTION OF PROPERTY
Name of Designating Body Resolution Number
Location of Property County DLGF Taxing District Number
Description of Manufacturing Equipment, Research Development Equipment, Logistical Distribution Equipment, or Information Technology Equipment (Use additional sheets, if necessary)
SECTION 3 EMPLOYEES AND SALARIES
As Estimated on SB-1/UD Actual
Current Number of Employees
Salaries
Number of Employees Retained
Salaries
Number of Additional Employees
Salaries
SECTION 4 COST AND VALUES
Manufacturing Equipment Research & Development Logistical Distribution Information Technology
Equipment Equipment Equipment
AS ESTIMATED ON SB-1/UD Cost Assessed Value Cost Assessed Value Cost Assessed Value Cost Assessed Value
Values Before Project
Plus: Values of Proposed Project
Less: Values of Any Property Being Replaced
Net Values Upon Completion of Project
ACTUAL
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
As Estimated on SB-1/UD 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)
Printed Name of Authorized Representative Email Address Telephone Number
( )
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