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               STATEMENT OF BENEFITS                                                                                               20____ PAY 20____
               REAL ESTATE IMPROVEMENTS
               State Form 51767 (R6 / 10-14)                                                                                       FORM SB-1 / Real Property
               Prescribed by the Department of Local Government Finance
                                                                                                                                   PRIVACY NOTICE
This statement is being completed for real property that qualifies under the following Indiana Code (check one box):               Any information concerning the cost 
 Redevelopment or rehabilitation of real estate improvements (IC 6-1.1-12.1-4)                                                     of the property and specific salaries 
                                                                                                                                   paid to individual employees by the 
 Residentially distressed area (IC 6-1.1-12.1-4.1)                                                                                 property owner is confidential per 
                                                                                                                                   IC 6-1.1-12.1-5.1.
INSTRUCTIONS:  
1.  This statement must be submitted to the body designating the Economic Revitalization Area prior to the public hearing if the designating body requires 
 information from the applicant in making its decision about whether to designate an Economic Revitalization Area.  Otherwise, this statement must be 
 submitted to the designating body BEFORE the redevelopment or rehabilitation of real property for which the person wishes to claim a deduction. 
2.  The statement of benefits form must be submitted to the designating body and the area designated an economic revitalization area before the initiation of      
 the redevelopment or rehabilitation for which the person desires to claim a deduction.
3.  To obtain a deduction, a Form 322/RE must be filed with the County Auditor before May 10 in the year in which the addition to assessed valuation is             
      made or not later than thirty (30) days after the assessment notice is mailed to the property owner if it was mailed after April 10.  A property owner who  
 failed to file a deduction application within the prescribed deadline may file an application between March 1 and May 10 of a subsequent year.
4.  A property owner who files for the deduction must provide the County Auditor and designating body with a Form CF-1/Real Property.  The Form CF-1/Real  
 Property should be attached to the Form 322/RE when the deduction is first claimed and then updated annually for each year the deduction is applicable.  
 IC 6-1.1-12.1-5.1(b)   
5.  For a Form SB-1/Real Property that is approved after June 30, 2013, the designating body is required to establish an abatement schedule for each 
 deduction allowed.  For a Form SB-1/Real Property that is approved prior to July 1, 2013, the abatement schedule approved by the designating body 
 remains in effect.  IC 6-1.1-12.1-17 
 SECTION 1                                                                  TAXPAYER INFORMATION
Name of taxpayer

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

Name of contact person                                                      Telephone number                         E-mail address
                                                                            (            )
 SECTION 2                                   LOCATION AND DESCRIPTION OF PROPOSED PROJECT
Name of designating body                                                                                             Resolution number

Location of property                                                        County                                   DLGF taxing district number

Description of real property improvements, redevelopment, or rehabilitation (use additional sheets if necessary)     Estimated start date (month, day, year)

                                                                                                                     Estimated completion date (month, day, year)

 SECTION 3                              ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PROJECT
Current number           Salaries                  Number retained             Salaries                          Number additional Salaries

 SECTION 4                                   ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT
                                                                                                                 REAL ESTATE IMPROVEMENTS
                                                                                                COST                               ASSESSED VALUE
 Current values
 Plus estimated values of proposed project
 Less values of any property being replaced
 Net estimated values upon completion of project
 SECTION 5                                   WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER
 Estimated solid waste converted (pounds) ________________________             Estimated hazardous waste converted (pounds) ___________________
 Other benefits

 SECTION 6                                                        TAXPAYER CERTIFICATION
 I hereby certify that the representations in this statement are true.
 Signature of authorized representative                                                                              Date signed (month, day, year)

 Printed name of authorized representative                                                Title

                                                                            Page 1 of 2

                                                       FOR USE OF THE DESIGNATING BODY
We find that the applicant meets the general standards in the resolution adopted or to be adopted by this body.  Said resolution, passed or to be passed 
under IC 6-1.1-12.1, provides for the following limitations:
   A.  The designated area has been limited to a period of time not to exceed ____________ calendar years*   (see below).  The date this designation 
       expires is _______________________________.
   B.  The type of deduction that is allowed in the designated area is limited to:
       1. Redevelopment or rehabilitation of real estate improvements             Yes           No
       2. Residentially distressed areas                                          Yes           No
 
   C.  The amount of the deduction applicable is limited to $ __________________.
   D.  Other limitations or conditions (specify)__________________________________________________________________________
   E.  Number of years allowed:               Year 1                  Year 2      Year 3              Year 4             Year 5  (* see below)
                                              Year 6                  Year 7      Year 8              Year 9             Year 10
   F.  For a statement of benefits approved after June 30, 2013, did this designating body adopt an abatement schedule per IC 6-1.1-12.1-17?                     
             Yes No
       If yes, attach a copy of the abatement schedule to this form.
       If no, the designating body is required to establish an abatement schedule before the deduction can be determined.
We have also reviewed the information contained in the statement of benefits and find that the estimates and expectations are reasonable and have 
determined that the totality of benefits is sufficient to justify the deduction described above.
Approved (signature and title of authorized member of designating body)       Telephone number                Date signed (month, day, year)
                                                                              (            )
Printed name of authorized member of designating body                         Name of designating body

Attested by (signature and title of attester)                                 Printed name of attester

* If the designating body limits the time period during which an area is an economic revitalization area, that limitation does not limit the length of time a 
taxpayer is entitled to receive a deduction to a number of years that is less than the number of years designated under IC 6-1.1-12.1-17.
   
   A.  For residentially distressed areas where the Form SB-1/Real Property was approved prior to July 1, 2013, the deductions established in IC               
       6-1.1-12.1-4.1 remain in effect. The deduction period may not exceed five (5) years.  For a Form SB-1/Real Property that is approved after June 30,  
       2013, the designating body is required to establish an abatement schedule for each deduction allowed.  The deduction period may not exceed ten  
       (10) years.  (See IC 6-1.1-12.1-17 below.)
   B.  For the redevelopment or rehabilitation of real property where the Form SB-1/Real Property was approved prior to July 1, 2013, the abatement            
       schedule approved by the designating body remains in effect. For a Form SB-1/Real Property that is approved after June 30, 2013, the designating  
       body is required to establish an abatement schedule for each deduction allowed. (See IC 6-1.1-12.1-17 below.) 
IC 6-1.1-12.1-17
Abatement schedules
Sec. 17. (a) A designating body may provide to a business that is established in or relocated to a revitalization area and that receives a deduction under
section 4 or 4.5 of this chapter an abatement schedule based on the following factors:
                 (1)  The total amount of the taxpayer's investment in real and personal property.
                 (2)  The number of new full-time equivalent jobs created.
                 (3)  The average wage of the new employees compared to the state minimum wage.
                 (4)  The infrastructure requirements for the taxpayer's investment.
           (b)  This subsection applies to a statement of benefits approved after June 30, 2013.  A designating body shall establish an abatement schedule  
                  for each deduction allowed under this chapter.  An abatement schedule must specify the percentage amount of the deduction for each year of  
                  the deduction.  An abatement schedule may not exceed ten (10) years.
           (c)   An abatement schedule approved for a particular taxpayer before July 1, 2013, remains in effect until the abatement schedule expires under  
                  the terms of the resolution approving the taxpayer's statement of benefits.

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