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                             STANDARD FORM AGREEMENT 
                             TO FOREGO PTABOA HEARING OR TO STIPULATE TO ASSESSED VALUE BY WAY OF APPRAISAL 
                             State Form 55853 (R / 12-18) 
                             Prescribed by the Department of Local Government Finance 
 
Indiana Code 6-1.1-15-2.5 allows a taxpayer and township or county official to enter into a written agreement in which both parties:  
                (1)  forego a Property Tax Assessment Board of Appeals (“PTABOA”) hearing and directly appeal to the Indiana Board of Tax Review 
                (“IBTR”); or 
                (2)  stipulate to the assessed value of the tangible property in dispute as determined by an independent appraisal under the terms and 
                conditions in IC 6-1.1-15-2.5(e). 
If the taxpayer and assessor choose to enter into such an agreement, the agreement must be entered into by both parties within 120 days after the 
taxpayer’s notice of review was filed. This agreement will not prohibit a taxpayer and assessor from resolving issues regarding assessed value or 
deductions in an informal conference under IC 6-1.1-15-1.2. When the agreement is made, the assessor must immediately forward the agreement to 
the PTABOA. This form must be notarized. 
 
                            I. THIS SECTION MUST BE COMPLETED REGARDLESS OF WHETHER SECTION II OR SECTION III IS SELECTED. 
 
Street address of property under appeal (number and street, city, and ZIP code): _____________________________________________________ 
 
Parcel number of property under appeal: _____________________________________________________________________________________ 
 
Assessment date under appeal (month, day, year): _____________________________________________________________________________ 
 
Is a tax representative acting on behalf of the taxpayer?      Yes   No  If yes, attach Power of Attorney (unless representative is taxpayer’s attorney). 
 
If yes, state name of tax representative: ______________________________________________________________________________________ 
 
Mailing address of taxpayer or tax representative, if different from address above (number and street, city, state, and ZIP code): 
 
______________________________________________________________________________________________________________________ 
 
Telephone number of taxpayer or tax representative, as applicable: ________________________________________________________________ 
 
E-mail address of taxpayer or tax representative, as applicable: ___________________________________________________________________ 
 
Mailing address of assessor (number and street, city, and ZIP code):_______________________________________________________________ 
 
 ______________________________________________________________________________________________________________________ 
                II. THIS SECTION TO BE COMPLETED IF TAXPAYER AND ASSESSOR AGREE TO FOREGO PTABOA HEARING AND APPEAL DIRECTLY 
TO IBTR. THE TAXPAYER’S SIGNATURE MUST BE NOTARIZED. ASSESSOR AND TAXPAYER MUST EACH KEEP A COPY OF THIS FORM. 
                ASSESSOR SHALL FORWARD A COPY TO THE PTABOA. TAXPAYER SHALL FORWARD A COPY TO THE IBTR. IF COMPLETING THIS 
                SECTION, DO NOT COMPLETE SECTIONS III THROUGH V.    PLEASE NOTE: A TAXPAYER WHO ELECTS TO APPEAL DIRECTLY TO THE 
                IBTR MUST, WITHIN 45 DAYS OF FILING THIS STANDARD FORM AGREEMENT WITH THE IBTR, FILE A SEPARATE APPEAL PETITION, 
                ON THE APPROPRIATE FORM, WITH THE IBTR PURSUANT TO IC 6-1.1-15-3. IBTR FORM INFORMATION IS AVAILABLE AT 
                                                          WWW.IN.GOV/IBTR OR BY CALLING 317-232-3786. 
                                                                                       
I (taxpayer), ______________________________________________________________,  
 
and I (assessor),   ________________________________________________________, Assessor of _____________________ County, Indiana,  
 
agree to forego a hearing by the PTABOA of _____________________ County, Indiana, and appeal directly to the IBTR. 
 
Signature of taxpayer:_____________________________________________________ Date (month, day, year):__________________________ 
 
Subscribed and sworn to before me this _____ day of _________________, 20_____. 
 
____________________________________________________________________ 
(Signature of Notary Public) 
 
________________________________________________________, Notary Public 
(Printed Name of Notary Public) 
 
____________________________ County, State of __________________________ 
 
My commission expires: ___________________________________, ____________ 
 
     Signature           of assessor:______________________________________________________ Date(month, day, year):__________________________ 
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III. THIS SECTION TO BE COMPLETED IF TAXPAYER AND ASSESSOR AGREE TO STIPULATE TO THE ASSESSED VALUE OF PROPERTY 
  BY WAY OF AN INDEPENDENT APPRAISAL. THE TAXPAYER’S SIGNATURE MUST BE NOTARIZED. ASSESSOR AND TAXPAYER MUST 
                     EACH KEEP A COPY OF THIS FORM. ASSESSOR SHALL FORWARD A COPY TO THE PTABOA. 
                                                                
1) The PTABOA must select three Indiana registered appraisers as potential appraisers to conduct an independent appraisal. 
2) No later than fifteen (15) days after the PTABOA chooses the potential appraisers, the taxpayer and the township or county official may each 
  strike one (1) appraiser from the list of potential appraisers by providing written notice to the PTABOA of the name of the appraiser the party 
  chooses to strike. 
3) No later than sixty (60) days after the date of the agreement, an independent appraisal must be conducted. If both the taxpayer and assessor 
  have chosen to strike an appraiser from the PTABOA’s list of potential appraisers, the remaining appraiser shall perform the appraisal. If only one 
  or neither of the parties has chosen to strike an appraiser from the list—that is, there are two (2) or three (3) appraisers who were not struck from 
  the list—then the PTABOA will choose the appraiser who will perform the appraisal. 
4) The appraisal must be: (i) performed in accordance with the usual and customary professional standard for an Indiana registered appraiser; (ii) 
  notarized; and (iii) filed with the PTABOA no later than three (3) days after the appraisal is completed. 
5) The taxpayer and the township or county official stipulate for purposes of review by the PTABOA that the correct assessed value of the tangible 
  property in dispute is the appraised value as determined by the appraisal. 
6) The taxpayer and the township or county official retain the right to initiate a proceeding for review the stipulated determination before the IBTR. 
 
Signature of taxpayer:______________________________________________________ Date (month, day, year):__________________________ 
 
Subscribed and sworn to before me this ______ day of __________________, 20_____. 
 
______________________________________________________________________ 
(Signature of Notary Public) 
 
__________________________________________________________, Notary Public 
(Printed Name of Notary Public) 
 
________________________________ County, State of _________________________ 
 
My commission expires: ______________________________________, ____________ 
 
Signature of assessor:______________________________________________________ Date(month, day, year):__________________________ 
 IV. THIS SECTION TO BE COMPLETED BY PTABOA AFTER IT RECEIVES A COPY OF THIS FORM WITH SECTION III COMPLETED. ONCE 
           THE PTABOA COMPLETES THIS SECTION, THIS FORM SHALL BE RETURNED TO THE ASSESSOR AND TAXPAYER. 
                                                                
The PTABOA of ________________________ County, Indiana, selects the following three Indiana registered appraisers as potential appraisers to 
conduct an independent appraisal of the property under appeal: 
______________________________________      _____________________________________      _____________________________________ 
The PTABOA understands that no later than sixty (60) days after the date of the agreement entered into by the taxpayer and assessor, an 
independent appraisal must be conducted. If both the taxpayer and assessor have chosen to strike an appraiser from the PTABOA’s list of potential 
appraisers, the remaining appraiser shall perform the appraisal. If only one or neither of the parties has chosen to strike an appraiser from the list—
that is, there are two (2) or three (3) appraisers who were not struck from the list—then the PTABOA will choose the appraiser who will perform the 
appraisal. The appraisal must be: performed in accordance with the usual and customary professional standard for an Indiana registered appraiser; 
notarized; and filed with the PTABOA no later than three (3) days after the appraisal is completed. When the PTABOA receives the completed 
appraisal pursuant to the agreement, it must enter a stipulated determination of assessed value 1) based on the agreement of the parties; and 2) 
equal to the appraised value of the property determined by the appraisal. If the PTABOA’s determination is in the form of a stipulated determination, 
notice to the parties must be given no later than thirty (30) days after entry of the stipulated determination. 
 
Signature of PTABOA member:_________________________________________________ Date (month, day, year):_______________________ 
Signature of PTABOA member:_________________________________________________ Date (month, day, year):_______________________ 
Signature of PTABOA member:_________________________________________________ Date (month, day, year):_______________________ 
Signature of PTABOA member:_________________________________________________ Date (month, day, year):_______________________ 
Signature of PTABOA member:_________________________________________________ Date (month, day, year):_______________________ 
 
 V. THIS SECTION TO BE COMPLETED BY TAXPAYER AND ASSESSOR ONCE PTABOA HAS COMPLETED SECTION IV. ONCE TAXPAYER 
AND ASSESSOR HAVE COMPLETED THIS SECTION, ASSESSOR SHALL RETURN THIS FORM TO THE PTABOA. THIS SECTION MUST BE 
             COMPLETED NO LATER THAN 15 DAYS AFTER THE PTABOA CHOOSES THE PROPOSED APPRAISERS. 
 
I (taxpayer), _____________________________________________, strike _________________________ from the list of the PTABOA’s proposed 
appraisers (if not striking a name, insert N/A). 
 
Signature of taxpayer:________________________________________________________ Date (month, day, year):________________________ 
 
I (assessor), ______________________________________________________________, Assessor of _____________________ County, Indiana,  
 
strike ___________________________________________ from the list of the PTABOA’s proposed appraisers (if not striking a name, insert N/A). 
 
Signature of assessor:______________________________________________________ Date(month, day, year):__________________________ 

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