REPORT TO COUNTY AUDITOR OF ADDED                                                                  FORM                Page 
                                                                                                                                    ______ of ______   
         ASSESSMENTS AND ASSESSMENT PENALTIES                                                               122A   
         State Form 22691 (R5 / 9-24)  
         Prescribed by the Department of Local Government Finance 
   
 INSTRUCTIONS:  1. If the penalty is for (a) or (b) below, indicate the penalty being applied in the left-hand column and place the appropriate dollar amount in 
               the space provided. 
         2. If the penalty is for (c) or (d) below, indicate ONLY the assessed value subject to the penalty in the appropriate column. 
         3. Where the assessor has granted an extension of time for filing the personal property tax return, the penalty imposed under (c) below 
               does not apply until thirty (30) days after the expiration of the extension. 
         4. A penalty is due with an installment under (a), (b), (c), or (d) below whether or not an appeal is filed under IC 6-1.1-15-5 with respect to 
               the tax due on that installment. 
         5. The purpose of this form is to be an internal transmittal from the assessing official to the county auditor. 
                                                          TO THE COUNTY AUDITOR 
   You are hereby notified that the following taxpayers have received added assessments or have penalties to be added to their assessments 
   for one (1) or more of the following reasons: 
   a. Failure 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. Failure to file a required personal property return on or before the due date (IC 6-1.1-37-7(a)). 
   c. Failure to file the personal property return on or before November 15 of a year (IC 6-1.1-37-7(a)(1)). 
   d. Failure to file the personal property return until after November 15 of a year (IC 6-1.1-37-7(a)(2)). 
   e. Undervaluing the property that he reports 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)). 
   NOTE: County auditor shall add penalties provided in IC 6-1.1-37-7. 
  County                                         Township                                                    Tax District 

                                                                                                        PENALTIES FROM INSTRUCTIONS ABOVE 
                                                                                            a or b                 c            d               e 
         NAME AND ADDRESS          ASSESSMENT     ADDED                 TOTAL      Indicate (a) or           No return filed on No return filed 20% of tax 
                                                                                                                   or before    until after 
         OF TAXPAYER                   YEAR       ASSESSMENT            ASSESSMENT (b) in left-hand             November 15     November 15     undervalued 
         (1)                           (2)                (3)           (4)        column                    (Lesser of 10%     (Lesser of 20%  personal 
                                                                                                                or $10,000)     or $20,000)     property 
                                                                                            $25.00                 ASSESSED VALUE SUBJECT TO PENALTY 
                                                                                                                                                 
  Signature of Assessing Official                         Title                                                                 Date Signed (month, day, year)