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                        AUTHORIZATION FOR RECEIPT OF ELECTRONIC                                                                          YEAR 
                        PROPERTY TAX STATEMENTS
                        State Form 53954 (6-09)                                                                                          File Mark
                        Prescribed by the Department of Local Government Finance pursuant to IC 6-1.1-22-8.1(j)

INSTRUCTIONS:
To be filed in person or by mail with the county auditor or county treasurer of the county where the property is located.
Filing date: Thirty (30) days prior to the anticipated general mailing date of property tax statements.
See reverse side for additional instructions and qualifications.

                                                                 APPLICANT INFORMATION
Name of applicant                                                                                      Telephone number

                                                                                                         (          )
Mailing Address (number and street or P.O. box, city, state, and ZIP code)

By submitting this application, I wish to:
            Receive electronic tax statements.                       Change e-mail address.                        Cancel electronic tax statements.
            (See Section A below.)                                   (See Section B below.)                        (See Section C below.)
                                   PROPERTY INFORMATION (ATTACH ADDITIONAL SHEETS AS NECESSARY)
Parcel A: Address (number and street, city, state, and ZIP code)                                       Parcel number

Parcel B: Address (number and street, city, state, and ZIP code)                                       Parcel number

Parcel C: Address (number and street, city, state, and ZIP code)                                       Parcel number

Parcel D: Address (number and street, city, state, and ZIP code)                                       Parcel number

                        SECTION A - CERTIFICATION FOR RECEIPT OF ELECTRONIC PROPERTY TAX STATEMENT 
I certify that I wish to receive electronic property tax statements at the following e-mail account. I understand that, by making this request, I will no 
longer receive property tax statements through the mail. Further, I understand that, if I later wish to change my e-mail address or begin receiving 
property tax statements through the mail, I must resubmit this form at least 30 days prior to the county's anticipated tax bill mailing date in a given 
tax year in order for the changes to take effect.
Signature of individual to receive electronic property tax statement           E-mail address

Signature of authorized representative                                         Company

                  SECTION B - CHANGE OF E-MAIL ADDRESS FOR RECEIPT OF ELECTRONIC PROPERTY TAX STATEMENT 
I certify that I wish to receive electronic property tax statements at the following e-mail account. I understand that, by making this request, I will no 
longer receive electronic property tax statements at my prior e-mail address. Further, I understand that, at such time as I wish to change e-mail 
addresses or begin receiving tax statements through the mail, I must resubmit this form at least 30 days prior to the county's anticipated tax bill 
mailing date in a given tax year in order for the changes to take effect.
Signature of individual to receive property tax statement            New e-mail address                            Prior e-mail address

Signature of authorized representative                               Company

                        SECTION C - TERMINATION OF ELECTRONIC PROPERTY TAX STATEMENT OPTION
I certify that I no longer wish to receive electronic property tax statements at the following e-mail account. I understand that, by making this request, I 
will once again receive property tax statements through the mail and that those statements will no longer be sent to this e-mail address. I understand 
that, at such time as I choose to receive tax statements electronically, I must re-file this form at least 30 days prior to the county's anticipated tax bill 
mailing date in a given tax year in order for the changes to take effect.

Signature of individual to receive property tax statement                      E-mail address

Signature of authorized representative                                         Company

            -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                 RECEIPT FOR ELECTRIONIC TAX BILL APPLICATION 
Name of applicant                                                    E-mail address                                Date filed (month, day, year)

Total number of parcels                   Parcel A                                                     Parcel B

                                          Parcel C                                                     Parcel D

Request type
            Receive electronic tax statements                        Change e-mail address                         Cancel electronic tax statements
Signature of county auditor or treasurer                                                               Date signed (month, day, year)

                                INSTRUCTIONS AND QUALIFICATIONS 
 
GENERAL INSTRUCTIONS 
 
 • Applications must be filed thirty (30) days prior to the anticipated general mailing date of property tax statements.  
    
 • This application may be filed with either the county auditor or county treasurer in person or by mail. If mailed, the 
   mailing must be postmarked on or before the last day of filing.  
 
ELIGIBILITY AND LIMITATIONS 
    
 • Electronic billing is not available in all counties. Please contact the county auditor or treasurer for availability. 
  
 • Upon successful filing, the election to receive property tax statements remains in effect until the owner of record 
   or authorized representative re-files the form to modify the address or cancel the request. 
  
 • Tax statements can only be sent to one e-mail address, regardless of the number of owners or persons liable for 
   property taxes.  
  
 • In order for an election to go into effect, each party liable for taxes must agree to designate one individual as the 
   primary recipient of tax information. A signed statement of agreement from each additional owner must be 
   attached to this application. 
  
 • A taxpayer may receive electronic statements for each parcel owned within an authorizing county. For more than 
   four parcels, an addendum of the other parcels must be attached to this application. 
  
 • If the county treasurer receives notification that the transmission of the electronic statement was not received, the 
   treasurer shall mail a hard copy of the property tax statement to the tax billing address on file for the property. The 
   payment due date remains the same as it was when the statement was originally sent by e-mail. 
  
 • Once an election to receive electronic tax statements takes effect, the taxpayer will no longer receive tax 
   statements through the mail. If an individual wishes to resume receiving tax statements by mail, the taxpayer must 
   re-submit this form at least thirty (30 )days prior to the anticipated general mailing date of property tax statements. 
  
 • If the county auditor receives notification that an electronic transmission was not received, the auditor shall mail a 
   hard copy of the information or statement to the tax billing address on file for the property. Due dates, if any, 
   remain the same as when the statement was originally sent by e-mail.