State Form 51767 - Statement Of Benefits Real Estate Improvements - 2011
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STATEMENT OF BENEFITS
20____ PAY 20____
REAL ESTATE IMPROVEMENTS
FORM SB-1 / Real Property
State Form 51767 (R3 / 12-11)
Prescribed by the Department of Local Government Finance
This statement is being completed for real property that qualifies under the following Indiana Code (
):
Redevelopment or rehabilitation of real estate improvements (IC 6-1.1-12.1-4)
Eligible vacant building (IC 6-1.1-12.1-4.8)
BEFORE
BEFORE
SECTION 1
TAXPAYER INFORMATION
Name of taxpayer
Address of taxpayer
Name of contact person
T elephone 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
Estimated start date (
)
Estimated completion date (
)
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
NOTE: Pursuant to IC 6-1.1-12.1-5.1 (d) (2) the COST of the property
is confidential.
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
WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER
SECTION 5
Estimated solid waste converted (
) ________________________
Estimated hazardous waste converted (
) ___________________
Other benefits
SECTION 6
TAXPAYER CERTIFICATION
I hereby certify that the representations in this statement are true.
Signature of authorized representative
Title
Date signed
Page 1 of 2
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