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FORM 1
PLACEMENT

month, day, year
(month, day, year)
DATE OF

Date signed (

of the mobile home.  (IC 6-1.1-7-3)
(name and license number)
Parcel number MANUFACTURED HOME INSTALLER
the land or lot owned, controlled, and/or possessed by me.

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

(address, lot number, etc.)
(number and street, city, state, and ZIP code) SITE LOCATION INFORMATION Page 1 of 2

(number and street, city, state, and ZIP code) Printed name of owner/possessor/controller of the land or lot

NUMBER

VEHICLE
Township

IDENTIFICATION
Address of owner, possessor, or controller of the land or lot Address of owner of the mobile home Address of contract buyer of the mobile home 

DIMENSION

MODEL

1.  Please type or print legibly. 2.  This form is to be filed with the township assessor, if any, or the county assessor within thirty (30) days after the date of placement 3.  Complete all boxes. If additional space is needed, attach a second form. 4.  For contact information for the township assessor or the county assessor, go to http://www.in.gov/dlgf/2440.htm. 5.  A person who violates this requirement commits a Class C infraction.  (IC 6-1.1-7-13) 6.  If applicable, information regarding the manufactured home installer must be provided, including the installer's name and license number (e.g. MHXXXXXXXX). 7.  A person who operates a mobile home community is also required to complete page 2 of this form.
NOTICE OF PLACING OF MANUFACTURED (MOBILE) HOME UPON LAND OR LOT State Form 23341 (R8 / 3-20) Prescribed by the Department of Local Government Finance MAKE
      
     Pursuant to the provisions of IC 6-1.1-7-3, you are hereby notified that the following mobile home(s) has been permitted to be placed on
INSTRUCTIONS:       Name of owner, possessor, or controller of the land or lot Name of owner of the mobile home Name of contract buyer of the mobile home Legal description of land or lot County YEAR Describe any unique / special circumstances that exist. Signature of owner/possessor/controller of the land or lot

ADDITIONAL INFORMATION REQUIRED FOR ACTIVITIES 
IN A MOBILE HOME COMMUNITY
Part of State Form 23341 (R8 / 3-20) 
Prescribed by the Department of Local Government Finance

INSTRUCTIONS:  A person who operates a mobile home community shall furnish the following information and other items to the assessor of the township in 
which the mobile home community is located, or the county assessor if there is no township assessor for the township, within thirty (30) 
days after the mobile home is placed in the mobile home community. This thirty (30) day period commences the day after the day that the 
mobile home is placed upon the land. (Indiana Code 6-1.1-7-3)
Name of mobile home community                                          Name of operator of mobile home community

In addition to the information provided on Page 1, disclose if any of the following apply:
If a person places a mobile home or allows a mobile home to be placed in the mobile home community
If a sale or lease of a mobile home previously held as inventory occurs
If the status of a mobile home is changed to inventory

Provide the following information:
(1) If applicable, notice of the sale or lease of the mobile home or the change in status of the mobile home to inventory.

(2) If applicable, the sales price of the mobile home.

(3) The name of the owner of the mobile home at the time the entry is made, as shown on the title to the mobile home.

(4) The vehicle identification number of the mobile home.

(5) Attach a copy of the title held by the owner of the mobile home at the time the entry is made, or, if no title exists attach either:
(A) a petition filed with a court requesting an order by the court for the title of the mobile home; or
(B) a bureau of motor vehicles affidavit of sale or disposal.

(6) Attach a copy of the most recent mobile home permit issued to the owner of the mobile home or issued under IC 6-1.1-7-10, if applicable.

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