REPORT OF ASSESSMENT FOR OMITTED OR                                                                    FORM 122 
                  UNDERVALUED PROPERTY ASSESSMENT                                                                  Assessment Year 
                  AND ASSESSMENT PENALTIES                                                                         January 1, 20______ 
                  State Form 9283 (R7 / 7-24)  
                  Prescribed by the Department of Local Government Finance 
   
  INSTRUCTIONS:  This form is to be completed by the assessor and submitted to the county auditor. 
 
 You are hereby notified that the undersigned has assessed the taxpayer mentioned below for omitted or undervalued property as follows: 
  Name of Taxpayer                                                                                                 Assessment Year 

  Address (number and street, city, state, and ZIP code) 

  Taxing District                                              Township                             County 

  Original Personal Property Return Filed                                      Return Due Date 
                             _____________________________, 20 ______                               _____________________________, 20 ______ 
 
                                                                        ORIGINAL ASSESSMENT      ADDED ASSESSMENT        TOTAL ASSESSMENT 
          PERSONAL PROPERTY                                             $                      $                   $ 

                                       LAND                             $                      $                   $ 
          REAL ESTATE 
                                       IMPROVEMENTS                     $                      $                   $ 

          TOTAL                                                         $                      $                   $ 
  General Description of the Property: 

                  IN ADDITION TO THE ADDED ASSESSMENT(S) SHOWN ABOVE, THE FOLLOWING PENALTIES ARE TO BE ADDED. 
                                                                                                 PENALTIES 
  The county auditor shall add the penalty(s) to the 
                                                                               Lesser of 10% of Tax Lesser of 20% Tax or 20% of Tax on Undervalued 
  property tax installment next due for the return.                     $25.00 or $10,000                  $50,000                      Personal Property 
  (a) Fails to include on a personal property return the 
  information that the Department of Local Government Finance                                                                            
  requires. (IC 6-1.1-37-7(d); IC 6-1.1-3-9; IC 6-1.1-5-13) 
  (b) Fails to file a required personal property return on or 
  before the due date. (IC 6-1.1-37-7(a))                                                                                                
  (c) Fails to file the personal property return on or before 
  November 15 of a year. (IC 6-1.1-37-7(a)(1))                                                                                           
  (d) Files the personal property return after November 15 
  of a year. (IC 6-1.1-37-7(a)(2))                                                                                                       
  (d) Undervalues the property reported on a personal property 
  return and if the amount by which the person undervalues 
  that property exceeds five percent (5%) of the value which 
  should have been reported on that return, then the county                                                                              
  auditor shall add a penalty of twenty percent (20%) of the 
  additional taxes finally determined to be due as a result of 
  the undervaluation. (IC 6-1.1-37-7(e)) 
                   TOTAL PENALTIES TO BE ADDED                                                                                           
 
 A penalty is due with an installment under (a), (b), (c), or (d) whether or not an appeal is filed under IC 6-1.1-15-5 with respect to the tax due on that installment. 
 
  Signature of Official                                                 Title                                      Date (month, day, year) 

 ORIGINAL – County Auditor; DUPLICATE – Assessing Official