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Form 103-P (State Form 24056) - Claim For Exemption Of Air Or Water Pollution Control Facilities

CLAIM FOR EXEMPTION OF AIR OR

FORM 103-P

JANUARY 1, 20 ______

WATER POLLUTION CONTROL

For Assessor’s use only

PRIVACY NOTICE

FACILITIES

This form contains information

confidential pursuant to IC 6-1.1-35-9.

State Form 24056 (R11 / 11-16)

Prescribed by Department of Local Government Finance

INSTRUCTIONS: Attach to and file with Form 103-Long.

Name of taxpayer (please type or print)

County

Address where property is located (number and street, city, state, and ZIP code)

DLGF taxing district number

RETURN OF PERSONAL PROPERTY OF INDUSTRIAL WASTE CONTROL FACILITIES TO ELIMINATE WATER POLLUTION CLAIMED TO BE EXEMPT

FROM ASSESSMENT. You must forward a copy of this exemption claim to the Indiana Department of Environmental Management by Registered

or Certified Mail. (IC 6-1.1-10-10). Pursuant to IC 6-1.1-10-10, report below all personal property employed predominantly in the operation of an industrial

water treatment system for elimination of water pollution caused by industrial wastes. (See 50 IAC 4.2-11.1-2)

TOTAL COST

MONTH & YEAR ACQUIRED

TAX LIFE

ASSET DESCRIPTION - INDUSTRIAL WASTE CONTROL FACILITY

TOTAL COST AS SHOWN ON LINE 5, SCHEDULE A, FORM 103-LONG

Under the penalties of perjury, I hereby certify that this return to the best of my knowledge and belief, is true, correct and complete; and reports the

total cost of all personal property claimed by the taxpayer to be exempt from assessment and taxation pursuant to IC 6-1.1-10-10.

Signature of authorized person

Title

Date (month, day, year)

Signature of person preparing return based on all information of which he has any knowledge

Claim Air Pollution Control Exemption on page 2.

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