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                 APPLICATION FOR DEDUCTION FROM ASSESSED VALUATION 
                                                                                                                                             20___ PAY 20___
                 OF REHABILITATED STRUCTURES OVER FIFTY (50) YEARS OLD
                 State Form 49567 (R6 / 11-16) 
                 Prescribed by the Department of Local Government Finance                                                                         FORM  322A
SPECIAL NOTE:    No new deductions for the rehabilitation of structures over fifty (50) years old under IC 6-1.1-12-22 may be granted after the 
                               January 1, 2017 assessment date.
INSTRUCTIONS: Application must be filed with the county auditor in person or by mail in the year in which the addition to the assessed value is made.  
                      If notice of the addition to assessed value is not given to the property owner before December 1 of that year, this form may be filed  
                      not later than thirty (30) days after the date of the mailing of the notice.
                      This deduction is for buildings or structures (does not include land) that were erected at least fifty (50) years prior to this application.
County                                                         Township                                                DLGF taxing district number

The undersigned owner hereby applies to the County Auditor, pursuant to IC 6-1.1-12-22 through IC 6-1.1-12-24,  for a deduction from the increase in 
assessed valuation resulting from rehabilitation of the following described property:
Name of owner                                                  Address of property (number and street, city, state, and ZIP code)

Year building or structure originally erected                  Date of rehabilitation (month, day, year)               Cost of rehabilitation

Type of dwelling:     Single family dwelling                                        Kind of rehabilitation:
                      Other                                                                Significant Repairs               Replacements               Improvements
                                                      LEGAL DESCRIPTION AS FOUND ON TAX DUPLICATE
Section                                  Township                                   Range                                   Addition

Lot number                                                     Block number                                            Key or parcel number

        ASSESSED VALUE                                ASSESSED VALUE                         DIFFERENCE IN                          INCREASE IN A/V DUE
  AFTER REHABILITATION                         PRIOR TO REHABILITATION                     ASSESSED VALUE                           TO REHABILITATION *
  (IMPROVEMENTS ONLY)                              (IMPROVEMENTS ONLY)                 (IMPROVEMENTS ONLY)                          (DEDUCTION CLAIMED)

* The assessed value (A/V) eligible for the deduction is the increase in A/V resulting from the rehabilitation and does not include the increase in A/V which  
  resulted from the reassessment of the entire property.
                                                                               CERTIFICATION
I hereby certify that the representations on this application are true.
Signature of owner                                             Name of owner (print or type)                                        Date (month, day, year)

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

                  VERIFICATION BY ASSESSING OFFICIAL                                                     REDUCTION CALCULATION BY AUDITOR
1. Type of structure                                                                1. Amount of INCREASE attributed to rehabilitation (Same as #8 on left) *

2. Date erected (month, day, year)                                                  2. 50% of #1 above
                                                                                       $ 0.00
3. Date rehabilitated (month, day, year)                                            3. Maximum annual deduction  (For single family dwellings - $124,800;  
                                                                                      for other structures - $300,000.)
4. Date reassessed (month, day, year)

5. Date taxpayer notified of increase in assessed valuation (month, day, year)      4. Annual deduction (Lesser of #2 or #3)

6. Assessed valuation of improvements AFTER rehabilitation                          5. Date deduction approved (month, day, year)

7. Assessed valuation of improvements PRIOR TO rehabilitation                       6. First year of deduction (Year in which taxes on rehabilitated portion of property 
                                                                                     became payable.)
8. Amount of INCREASE attributed to rehabilitation *

9. Date verified (month, day, year)                                                 7. Fifth year of deduction

NOTE: Owner must have paid at least $10,000 for the rehabilitation.  A general reassessment or a cyclical reassessment which occurs within the
five (5) year period of the deduction does not affect the amount of the deduction.  (IC 6-1.1-12-22 and IC 6-1.1-12-23)
Signature of assessing official                                                Signature of county auditor