Form 137pf - Petition For Survey And Reassessment Real Property That Is Permanently Flooded Or Access Is Permanently Preventing By Flooding - Department Of Local Government Finance

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Date Petition Filed

PETITION FOR SURVEY AND REASSESSMENT

FOR OFFICE USE ONLY

FORM 137PF

REAL PROPERTY THAT IS PERMANENTLY FLOODED

OR ACCESS IS PERMANENTLY PREVENTED BY FLOODING

State Form 53950 (6-09)

Prescribed by the Department of Local Government Finance

INSTRUCTIONS (IC 6-1.1-4-11.5):

1. This form can be filed if one or more parcels of real property within a county are permanently flooded or to which access over land is permanently prevented

because of flooding.

2. This form cannot be used for real property being used for agricultural purposes.

3. The date when the flooding occurred must be reported on this form.

4. This form must be filed with the County Assessor by December 31st of the year the flooding occurred.

5. Once the assessor has made a determination on this petition and sends notice, the taxpayer must file an appeal within forty-five (45) days if he/she disagrees

with it. (IC 6-1.1-15-1)

Pursuant to IC 6-1.1-4-11.5, the undersigned hereby petitions the County Assessor for a survey and reassessment of real property described below.

(Description must match legal descrition on Tax Bill Duplicate.)

Name of taxpayer (first, middle, last)

Telephone number

(

)

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

Date of flood (month, day, year)

Type of damage

Permanent Flooding

Access Permanently Prevented by Flooding

County

Township

Parcel number

Section

Range

Lot number

Block

Addition

Location of property damaged (number and street or Rural Route, city, state, and ZIP code)

REAL PROPERTY REASSESSMENT

(Do not complete unless a reassessment is ordered.)

ASSESSED VALUE

ASSESSED VALUE OF

PERCENT OF

DATE

REASSESSMENT

OF LAND

IMPROVEMENTS

DAMAGE

(month, day, year)

(BY ASSESSOR)

AFFIDAVIT

I, under oath, hereby declare that the statements contained in this petition are true and correct and constitute the basis for the survey and reassessment.

Signature of taxpayer

Type or print name of taxpayer

Date signed (month, day, year)

Signature of assessor

Type or print name of assessor

Date signed (month, day, year)

COUNTY ASSESSOR ACTION

Reviewed by:

Date reviewed (month, day, year)

Ordered reassessed?

Date ordered reassessed (month, day, year)

Yes