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                                                                                                                                        Assessment date
               APPLICATION FOR PROPERTY TAX EXEMPTION                                                      FORM 136                    January 1, 20____
               State Form 9284 (R10 / 11-15)
                                                                                                                                  County
               Prescribed by Department of Local Government Finance

INSTRUCTIONS:  1.  Two copies of this form must be filed with the County Assessor of the county where the property is located.
                     2.  This application must be filed on or before April 1 of the assessment year and must be re-filed every even year unless the exempt 
                      property is owned, occupied, and used for educational, literary, scientific, religious, or charitable purposes and continues to meet the 
                      requirements of IC 6-1.1-10-16 or IC 6-1.1-10-21, or is owned by a fraternity or sorority and continues to meet the requirements of 
                      IC 6-1.1-10-24.  An application should be filed in any year in which an appeal to the Indiana Board of Tax Review or to a court for an 
                      exemption determination on the property is pending from any preceding year.
                     3.  There is no filing fee.
                     4.  All questions on page 1, 2, and 3 must be answered. If the question does not apply, write N/A in the space provided. FAILURE TO 
                      PROVIDE THE REQUESTED INFORMATION MAY RESULT IN A DENIAL OF THE APPLICATION FOR EXEMPTION. 
                      See page 5 for additional information.
Name of owner claiming exemption                                                                           Type of filing:
                                                                                                                First-time filing          Yes                   No 
Address (number and street, city, state, and ZIP code)                                                          Re-filing on same property Yes                   No
                                                                                                                Re-filing with changes     Yes                   No
 Telephone number                          E-mail address                                                  Describe these changes.
 (            )
Hereby petitions for exemption from taxation of the following described real estate and improvements and / or personal property:
                                       LAND                                                                IMPROVEMENTS (BUILDINGS)
                                                                          Assessed          Description of Improvements                    Assessed
                     Legal Description                                    Value            (Name or describe each building)                Value
                                                                $
                                                                                   1.                                                   $

                                                                                   2.                                                   $
                      Parcel Number
                                                                                   3.                                                   $

 Personal property assessment    Date of assessment              Township / Taxing District located in     DLGF taxing district number     Key number
 $                                     January 1, 20 _______
 Upon what uses or purpose do you base the claim for exemption?                    What percentage do you claim should be exempt on the value of:
   Charitable - pursuant to IC 6-1.1-10-16.                                        Land and lots
   Educational - pursuant to IC 6-1.1-10-16.
   Religious - pursuant to IC 6-1.1-10-16.                                         Improvements (buildings)
   Other - (cite the specific law(s) under which the exemption is claimed)         1.                  2.  3.
                                                                                   Personal property

 NOTE: The taxpayer must present evidence that the property qualifies for exemption under a SPECIFIC statute. Please indicate that the following  
             documentation has been provided:
               Articles of incorporation or other organizational documents
               Bylaws
   Financial statements for the last three years:
               Balance sheets                          If “Other” box is checked above - the specific statute under which the exemption is claimed must be cited.
               Summary of income and expenditure
 FAILURE TO PROVIDE SUCH DOCUMENTATION MAY BE GROUNDS FOR A DENIAL OF THE EXEMPTION SOUGHT.

                                                                           CERTIFICATE
 Under the penalties of perjury, I hereby certify that the statements in the application and information sheet are true and correct to the best of my knowledge and 
 belief, and are made for the purpose of having the property described hereon, or a part thereof, exempt from taxation. A person who signs an exemption 
 application shall attest in writing and under penalties of perjury that, to the best of the person’s knowledge and belief, a predominant part of the property claimed 
 to be exempt is not being used or occupied in connection with a trade or business that is not substantially related to the exercise or performance of the 
 organization’s exempt purpose. 
Signature of authorized representative                                                                                    Date signed (month, day, year)

Printed name of authorized representative                                                        Title

                                                                                Page 1 of 5

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REQUIRED INFORMATION
INSTRUCTIONS: Please state all information for the tax year in question. If you need additional space to answer any questions or wish to provide additional
information, use space at bottom of reverse side. Attach separate sheet if necessary.
I. GENERAL
1. Who owns the property? (Name, address, type of entity, and purpose for which entity was formed per articles of incorporation or similar documents)

2. Who occupies the property? (Name, address, type of entity, and purpose for which entity was formed per articles of incorporation or similar documents)

3. Who uses the property? (Name, address, type of entity, and purpose for which entity was formed per articles of incorporation or similar documents)

4. For how much land is the exemption claimed? (See IC 6-1.1-10-16(c) and (d), 6-1.1-10-20, 21, 22, and 26)

5. Describe all structures and state specifically the normal use of each room or area in each structure. (You may attach a diagram of the property and structures.)

II. EXEMPT PURPOSE
1. State specifically the exempt purpose and activities for which the property is used. (If any publications about the exempt activity are available, please provide a copy.)

2. State how often such activities occur.

3. State specifically what rooms or areas are used for the exempt purpose and what such use is. (Be sure all rooms or areas are discussed.)

4. Who carries out the exempt activities for which the property is used?

4a. State the qualifications of such individual(s).

4b. State if such individual(s) are certified or licensed by an entity, who has issued such certificate or license, and the qualifications required to obtain such certificate or license.

4c. How many individuals or groups participate in the exempt activities?

5. State what written materials, if any, are used.

6. What standards, if any, must individuals or groups benefiting from the exempt activity meet prior to participation in such activities?

7. State if the taxpayer is supervised by any entity, group or individual. 7a. State the name of such entity.

7b. State the address of the entity. 7c. State the nature and purpose of such entity.

III. OTHER INFORMATION
1. Are rooms or areas ever used by individuals or groups for purposes not related to the 1a. Name such individuals or groups.
claimed exempt use? (If “No”, skip to 2.) Yes No
1b. State specifically what rooms or areas are used by such individuals or groups. 1c. State specifically how often such individuals or groups use such rooms or areas.

2. Do those benefiting from the exempt activity ever use areas or rooms for activities not 2a. State who makes such use of rooms or areas.
directly related to the activity of the taxpayer? (If “No”, skip to 3.) Yes No
2b. State specifically what rooms or areas are so used. 2c. State specifically how often such rooms or areas are so used.

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REQUIRED INFORMATION (continued)

III. OTHER INFORMATION (continued)
3. Do the individuals whose activities are related to the exempt purpose ever use 3a. State who makes such use of rooms or areas.
rooms or areas for activities not directly related to the basis for the claimed
exemption? (If “No”, skip to 4.) Yes No
3b. State specifically what rooms or areas are so used. 3c. State specifically how often such rooms or areas are to be used.

4. Are fees ever charged to those who make use of rooms or 4a. State the uses for which such fees are charged.
areas? (If “No”, skip to 5.) Yes No
4b. State how often such fees are charged. 4c. State who is charged such fee. 4d. State what fee is charged.

4e. For what purpose is the revenue derived from such fee used? 5. How many individuals participate in the
exempt activities?
6. Are any rooms or areas ever used by any income generating 6a. State the activity.
activity? (If “No”, skip to 7.) Yes No
6b. State specifically where it occurs.

6c. State specifically how often it occurs. 6d. State who conducts such activity.

7. Are food or items of any sort ever sold? 7a. State what is sold.
(If “No”, skip to 8.) Yes No
7b. State specifically where it is sold.

7c. State specifically how often such sales occur. 7d. State specifically who makes such sales.

8. Are dances, dinners or other social functions ever held on the property for which the 8a. State the activity.
exemption is claimed? (If “No”, skip to 9.) Yes No
8b. State specifically where it occurs.

8c. State specifically how often it occurs. 8d. State who conducts such activity.

9. Are goods, crops, or food of any sort ever made, grown, or 9a. If so, specifically describe such goods, crops or food.
produced on the property? Yes No
9b. State specifically the number or amount of goods, crops or food made, grown or produced. 9c. State specifically where such goods, crops or food is made, grown or produced.

9d. State specifically who makes, grows, or produces such goods, crops or food. 9e. State the dollar value of each good, crop or food made, grown or produced.

Use this area if additional space is needed for answers or if you wish to provide additional information.

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ACTION BY THE COUNTY PROPERTY TAX ASSESSMENT BOARD OF APPEALS

INSTRUCTIONS: In order to grant an application for an exemption, in whole or in part, the County PTABOA must specifically find that the statutory
prerequisites for an exemption have been met. If any of the statutory conditions have not been met, the exemption CANNOT BE GRANTED.
If you need additional space to answer any questions or wish to provide additional information, please attach a separate sheet.
THE SECRETARY OF THE COUNTY PTABOA MUST ANSWER ALL QUESTIONS.
Name of taxpayer

EXEMPTION ALLOWED EXEMPTION NOT ALLOWED
ASSESSED
VALUE
DESCRIPTION PERCENT ASSESSED PERCENT ASSESSED
VALUE VALUE
Land and lots
1. $$$

3.
Improvements (Buildings)
1. $$$

3.
Personal property
1. $$$

3.
TOTALS $$$
0.00 0.00 0.00 0.00 0.00
Date application filed (month, day, year)
Was the entire application completely filled out (pages 1, 2, and 3)? Yes No

Was any information not in writing or on the form presented to the County PTABOA? If yes, complete next line. Yes No
State who presented the information and summarize the information provided.

Did the County PTABOA consider the actual use of the property? Yes No
What is the percentage of actual exempt use of each room, area, or building for which the exemption is claimed?

What is the exempt use of the property?

State the specific statute under which the application was granted or denied:

COUNTY PTABOA
Signature of County Assessor (Secretary of PTABOA) Date signed (month, day, year)

Printed name of County Assessor (Secretary of PTABOA)

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APPLICATION FOR PROPERTY TAX EXEMPTION - GENERAL INFORMATION

WHY MUST I FILE FOR AN EXEMPTION?
An exemption is a privilege which may be waived if an application for exemption is not timely filed. If an application for exemption is not filed, the County
Property Tax Assessment Board of Appeals (PTABOA) is without power to grant an exemption. Only property which the taxpayer shows is exempt pursuant to
statute may be granted an exemption. Generally, property may be granted an exemption only if it is used for the specific purposes set out in a specific statute.

WHAT PROPERTY MAY BE GRANTED AN EXEMPTION?
Property may be granted an exemption if an application has been timely filed and the property has been shown to qualify for an exemption specifically provided
by statute. Generally, such statutes require ownership of the property by a specified type of entity and use of the property for a specific purpose.

WHO MUST FILE?
The owner of property who wishes to obtain an exemption must file a certified application in duplicate.

WHERE MUST I FILE?
The application must be filed with the County Assessor of the county where the property is located.

WHEN MUST I FILE?
The exemption application must be filed on or before April 1 of the assessment year (the year prior to the tax billing date) and must be re-filed every even year
unless the exempt property is owned, occupied, and used for educational, literary, scientific, religious, or charitable purposes and continues to meet the
requirements of IC 6-1.1-10-16 or IC 6-1.1-10-21, or is owned by a fraternity or sorority and continues to meet the requirements of IC 6-1.1-10-24.
An application should be filed in any year in which an appeal to the Indiana Board of Tax Review or to a court for an exemption determination on the
property is pending from any preceding year.

WHAT MUST I FILE?
The owner of the property must file State Form 9284 / Form 136 with the County Assessor. The owner must provide all information requested on the
application and accompanying information sheet. There is no filing fee.

WHAT HAPPENS IF THE OWNERSHIP OR USE OF AN EXEMPT PROPERTY CHANGES?
If an exempt property is transferred or its use is changed after an assessment date, the transfer or change of use will not affect the property’s eligibility for an
exemption for that assessment date. For the following assessment date, the person that obtained the exemption or the current owner of the property, as
applicable, shall file a certified application in duplicate with the county assessor of the county in which the property that is the subject of the exemption is
located. In all cases, the person that obtained the exemption or the current owner of the property shall notify the county assessor for the county where the
tangible property is located of the change in ownership or use in the year that the change occurs.

WHY AM I NOT AUTOMATICALLY EXEMPT FOR PROPERTY TAX PURPOSES IF I AM EXEMPT FOR INCOME TAX PURPOSES?
The granting of a federal or state income tax exemption does not entitle a taxpayer to a property tax exemption because an income tax exemption does not
depend so much on how the property is used, but how the money is spent. (See Raintree Friends Housing, Inc. v. Indiana Department of Revenue, 667 N.E.
2d 810). It has also been determined that a worthwhile activity or noble purpose alone is not enough because a property tax exemption is justified when it
helps accomplish some public purpose. (See National Association of Miniature Enthusiasts v. State Board of Tax Commissioners, 671 N.E. 2d 218).

THE APPLICANT SHOULD MAKE A COPY OF THE COMPLETED FORM FOR HIS / HER RECORDS.

WHAT HAPPENS AFTER I FILE?
The application will be considered by the County PTABOA. If the application is rejected in whole or in part, notice of that action will be given to the applicant on
Form 120.

An applicant may appeal to the Indiana Board of Tax Review within thirty (30) days from the date the notice of rejection is given by the County PTABOA (IC
6-1.1-11-7). The appeal must be filed with the Indiana Board of Tax Review on the Form 132 and a copy mailed to the County Assessor (IC 6-1.1-15-3).

Before August 2nd, the County Assessor will forward to the Department of Local Government Finance the duplicate copy of each approved application. The
Department may review those applications and, upon notice and hearing, may deny any exemption if it determines that the property is not eligible for
exemption.

WHAT ACTIVITIES QUALIFY AS CHARITABLE, EDUCATIONAL, AND RELIGIOUS?
Charitable, educational, and religious activities are not defined in statute. Case law suggests that a variety of factors may be relevant and should be
considered. For examples of this case law, applicants could research the “Decisions” section of the Indiana Board of Tax Review’s website at www.in.gov/ibtr.
Applicants are encouraged to specify in as much detail as possible their precise use of the property and how that use substantially relates to the purposes that
they believe qualify the property for exempt status. Applicants should seriously consider consulting an attorney for assistance because qualification for
exemption often presents complex legal questions.

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