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             REPORT TO COUNTY AUDITOR OF ADDED                                                    FORM                        Page
             ASSESSMENTS AND ASSESSMENT PENALTIES                                                     122A                                      of
             State Form 22691 (R4 / 6-15)
             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 (6-1.1-37-7(d), 6-1.1-3-9, 
 6-1.1-5-13).
 b. Failure to file a required personal property return on or before the due date (6-1.1-37-7(a)).
 c. Failure to file the personal property return within thirty (30) days after the due date (6-1.1-37-7(a)).
 d. 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 (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
             NAME AND ADDRESS                 ASSESSMENT             ADDED                TOTAL                                    No return filed 20% of tax
              OF TAXPAYER                     YEAR                   ASSESSMENT ASSESSMENT                  Indicate (a) or (b) in within 30 days  undervalued
              (1)                             (2)                          (3)                    (4)       left hand column.      of due date     personal
                                                                                                                                   20% of tax      property
                                                                                                                  $25.00           ASSESSED VALUE
                                                                                                                                   SUBJECT TO PENALTY

 Signature of Assessing Official                                     Title                                                         Date signed (month, day, year)