Free 52584.FH11 - Indiana

PETITION FOR WAIVER OR REDUCTION OF PROPERTY TAXES AGAINST A BROWNFIELD
State Form 52584 (4-06) Prescribed by the State Board of Accounts and Approved by the Department of Local Government Finance, 2006

COUNTY FORM 137BR

INSTRUCTIONS:

1. This form is to be used by a person who owns or desires to own a brownfield and is seeking a reduction or waiver of the delinquent property tax liability. 2. This form is to be filed with the county auditor of the county in which the real property is located. 3. A separate form must be filed on each tax parcel. 4. If insufficient space exists to complete any part of this form, attachments are acceptable. 5. This waiver or reduction is subject to IC 6-1.1-45.5. PROPERTY INFORMATION

SECTION 1
Address of property (number and street, city, state, and ZIP code) County Name of owner Mailing address of owner (number and street, city, state, and ZIP code) Telephone number Fax number Township

DLGF taxing district number Name of contact person

Parcel number (file a separate form for each parcel)

(

)

(

)

E-mail address (optional)

Describe the conditions existing on the brownfield that have prevented the sale or the transfer of title to the county:

NOTE: Attach a statement from the Indiana Department of Environmental Management that the property is a brownfield (required for approval).

SECTION 2
Name of petitioner

PETITIONER INFORMATION
Name of contact person

Mailing address of petitioner (number and street, city, state, and ZIP code) Telephone number Fax number E-mail address (optional) Date of acquisition (month, day, year) Date plan is to be completed (month, day, year)

(

)

(

)

Describe the manner in which the petitioner acquired or proposes to acquire the brownfield Describe the plan the petitioner has for addressing any contaminants on the brownfield Describe the petitioners intended use of the brownfield Has the petitioner had an ownership interest in any entity that contributed to the contamination of the brownfield?

Yes

No

Has the petitioner contributed to the contamination of the brownfield even though they had no ownership interest?

Yes 8 9

No

SECTION 3 1
ASSESSMENT YEAR

2
PAYMENT YEAR

AMOUNT OF DELINQUENT TAX LIABILITY (obtain from county auditor) 3 4 5 6 7
AMOUNT OF DELINQUENT PROPERTY TAXES AMOUNT OF PENALTIES AMOUNT OF INTEREST COSTS AMOUNT OF SPECIAL ASSESSMENTS

TOTAL (3 + 4 + 5 + 6 + 7)

REQUESTED AMOUNT OF WAIVER OR REDUCTION

TOTALS
Can any part of the delinquent tax liability shown above be reasonably collected from a person other than the petitioner?
If the answer to the above question is Yes, give details:

Yes

No

Page 1

SECTION 4 The below signed petitioner seeks:

CERTIFICATION

a waiver of the total delinquent tax liability shown in section 3 of this petition; or a reduction of the delinquent tax liability in the amount of ________________________. I hereby certify that the above representations are true and correct.
Authorized signature of petitioner or representative (attach POA if representative) Printed name of signatory Title Date of signature (month, day, year)

Full mailing address of petitioner or representative (number and street, city, state, and ZIP code)

FOR USE BY COUNTY AUDITOR I, Auditor of the county below, hereby certify that this petition was filed with this office on the date noted below, and do hereby accept the petition.
Signature of county auditor Amount of fee charged County This space for official stamp of county auditor Date filed (month, day, year)

INSTRUCTIONS TO COUNTY AUDITOR: 1. Determine if the petition is complete. The petition must have entries in all spaces (except optional spaces). The petition must have attached: a. a letter from the Indiana Department of Environmental Management stating the parcel is a brownfield. b. any other attachments that are referenced in this petition. 2. If the petition is not complete, the petition should not be accepted. The petition should be returned to the petitioner with a description of the defects in the petition. 3. If the petition is complete, the petition should be accepted and a copy forwarded to: a. the assessor of the township in which the brownfield is located; b. the owner, if different from the petitioner; c. all persons that have, as of the date of the filing of the petition, a substantial property interest of public record in the brownfield; d. the county property tax assessment board of appeals; e. the county fiscal body; f. the Indiana Department of Environmental Management; and g. the Indiana Department of Local Government Finance. 4. The county auditor may charge a fee in an amount sufficient to cover the costs of: a. completing the title search; and b. processing the petition.

Page 2