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                                                                                     Number                   Date (month, day, year)
        NOTICE OF ASSESSMENT REGISTRATION
        State Form 786 (R3 / 6-16)                                                   County
        DEPARTMENT OF LOCAL GOVERNMENT FINANCE

INSTRUCTIONS: An owner of real property, or the owner’s agent, is required to file this notice with the County Assessor before demolishing, structurally modifying, 
or improving the property, unless the demolition, structural modification, or improvement: (1) requires a permit from the state or a political subdivision or (2) costs 
$500 or less for materials or labor, or both. Any owner who fails to file this notice when required is subject to a civil penalty of $100 (see IC 6-1.1-5-15)

                                   AMONG THE ITEMS SUBJECT TO THIS NOTICE ARE:
•  Construction or placement of building, swimming pool, or other yard structure
•  Horizontal or vertical extension of building, including extensions such as patios.
•  Major remodeling, including finishing of attic or basement.
• Addition (not replacement) of fireplace, central air conditioning, central heating, commercial paving, bath tub, sink, toilet, water heater.

                                                                    BASIC INFORMATION
Name of registrant                                                                                            Telephone number
                                                                                                              (           )
Address of registrant (number and street, city, state, ZIP code)

Name of landowner                                                                                             Telephone number
                                                                                                              (           )
Address of landowner (number and street, city, state, ZIP code)

                                                                LOCATION OF REAL PROPERTY
Section                 Township   Range                        Lot Block            Subdivision or addition

County road or street                                               City                    Parcel number

                                 DESCRIPTION OF DEMOLITION, STRUCTURAL MODIFICATION, OR IMPROVEMENT

                                   ESTIMATED COST INFORMATION IS CONFIDENTIAL PER IC 6-1.1-35-9.
                                                                    ESTIMATE
Cost of materials and labor                                              Commencement date (month, day, year) Completion date (month, day, year)

Signature of registrant                                                                                       Date signed (month, day, year)