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         COMPLIANCE WITH STATEMENT OF BENEFITS                                                    PRIVACY NOTICE                        20___ PAY 20___ 
                                                                                            The cost and any specific individual’s 
         VACANT BUILDING DEDUCTION                                                          salary information is confidential; the 
         State Form 55183 (R3 / 12-22)                                                      balance of the filing is public record      FORM CF-1 / VBD 
         Prescribed by the Department of Local Government Finance                                 per IC 6-1.1-12.1-5.3 (k) and (l). 
INSTRUCTIONS:    1.  Property owners must file this form with the county auditor and the designating body for their review regarding the compliance of the qualifying 
                       property with the Statement of Benefits (Form SB-1/VBD). 
                     2. This form must accompany the initial deduction application (Form 322-VBD) that is filed with the county auditor.
                     3. This form must also be updated each year in which the deduction is applicable. It is filed with the county auditor and the designating body before
                       May 15th or by the due date of the real property owner’s personal property return that is filed in the township where the property is located. (IC 
                       6-1.1-12.1-5.3(j)) 
SECTION 1                                                          TAXPAYER INFORMATION 
Name of Taxpayer                                                                                                 County 

Address of Taxpayer (number and street, city, state, and ZIP code)                                               DLGF Taxing District Number 

Name of Contact Person                                                                Telephone Number           Email Address 
                                                                                      (         ) 
SECTION 2                                     LOCATION AND DESCRIPTION OF PROPERTY 
Name of Designating Body                                                              Resolution Number          Estimated Occupancy Date (month, day, year) 

Location of Property                                                                                             Actual Occupancy Date (month, day, year) 

Description of eligible vacant building that the property owner or tenant will occupy                            Estimated Date Placed-In-Use (month, day, year) 

                                                                                                                 Actual Date Placed-In-Use (month, day, year) 

SECTION 3                                                          EMPLOYEES AND SALARIES 
                       EMPLOYEES AND SALARIES                                               AS ESTIMATED ON SB-1                                 ACTUAL 
Current Number of Employees 
Salaries 
Number of Employees Retained 
Salaries 
Number of Additional Employees 
Salaries 
SECTION 4                                                          COST AND VALUES 
       COST AND VALUES                                                                      REAL ESTATE IMPROVEMENTS 
AS ESTIMATED ON SB-1                                                  COST                                           ASSESSED VALUE 
Values Before Project                       $                                                           $ 
Plus: Values of Proposed Project            $                                                           $ 
Less: Values of Any Property Being Replaced $                                                           $ 
Net Values Upon Completion of Project       $                                                           $ 
ACTUAL                                                                COST                                           ASSESSED VALUE 
Values Before Project                       $                                                           $ 
Plus: Values of Proposed Project            $                                                           $ 
Less: Values of Any Property Being Replaced $                                                           $ 
Net Values Upon Completion of Project       $                                                           $ 
SECTION 5                UPDATES TO THE ANSWERS PROVIDED IN SECTION 5 OF THE FORM SB-1/VBD, IF ANY 
                                              (Attach additional sheet(s) if necessary) 

SECTION 6                                                          TAXPAYER CERTIFICATION 
I hereby certify that the representations in this statement are true. 
Signature of Authorized Representative                                                Title                                          Date Signed (month, day, year) 

                                                                      Page 1 of 2 

  OPTIONAL: FOR USE BY A DESIGNATING BODY WHO ELECTS TO REVIEW THE COMPLIANCE WITH THE FORM SB-1/VBD 

INSTRUCTIONS:  (IC 6-1.1-12.1-5.3 and IC 6-1.1-12.1-5.9) 
1. Not later than forty-five (45) days after receipt of this form, the designating body may determine whether or not the property owner has substantially 
   complied with the Statement of Benefits (Form SB-1/VBD).
2. If the property owner is found NOT to be in substantial compliance, the designating body shall send the property owner written notice. The notice must 
   include the reasons for the determination, including the date, time ,and place of a hearing to be conducted by the designating body. The date of this hearing 
   may not be more than thirty (30) days after the date this notice is mailed. A copy of the notice may be sent to the county auditor and the county assessor.
3. Based on the information presented at the hearing, the designating body shall determine whether or not the property owner has made reasonable effort sto 
   substantially comply with the Statement of Benefits (Form SB-1/VBD) and whether any failure to substantially comply was caused by factors beyond the 
   control of the property owner.
4. If the designating body determines that the property owner hasNOT made areasonable effort to comply, the designating body shall adopt a resolution                             
   terminating the property owner’s deduction. If the designating body adopts a resolution, the deduction does not apply to the next installment of property 
   taxes owed by the property owner or to any subsequent installment of property taxes. The designating body shall immediately mail a certified copy of the 
   resolution to: (1) the property owner; (2) the county auditor; and (3) the county assessor.

We have reviewed the CF-1 and find that: 

☐  The property owner IS in substantial compliance 

☐  The property owner IS NOT in substantial compliance 

☐  Other    (specify) _________________________________________________________________________________________________________ 
Reasons for the Determination (attach additional sheets if necessary) 

Signature of Authorized Member                                                                                                         Date Signed (month, day, year) 

Attested By                                                                 Designating Body 

If the property owner is found not to be in substantial compliance, the property owner shall receive the opportunity for a hearing. The following date and 
time has been set aside for the purpose of considering compliance. (Hearing must be held within thirty (30) days of the date of mailing this notice) 
Time of Hearing                   ☐      AM   Date of Hearing (month, day, year)     Location of Hearing 
                                  ☐      PM

                                            HEARING RESULTS (to be completed after the hearing) 
                               ☐  Approved                                                        ☐      Denied (see Instruction 4 above)
Reasons for the Determination (attach additional sheets if necessary) 

Signature of Authorized Member                                                                                                         Date Signed (month, day, year) 

Attested By                                                                 Designating Body 

                                                   APPEAL RIGHTS [IC 6-1.1-12.1-5.9(e)] 
A property owner whose deduction is denied by the designating body may appeal the designating body’s decision by filing a complaint in the office of the clerk of the Circuit or 
Superior Court together with a bond conditioned to pay the costs of the appeal if the appeal is determined against the property owner. 

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