Free 09284.FH11 - Indiana

APPLICATION FOR PROPERTY TAX EXEMPTION
State Form 9284 (R6 / 3-07)

FORM 136

Assessment date March 1, ________ County

Prescribed by Department of Local Government Finance

Reset Form
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 before May 15. An application must be filed in 2000 and in every even numbered year thereafter. However, an application must be filed in any other year if the property was not exempted in the immediately preceding year. An application should be filed in any year in which an appeal to the Indiana Board of Tax Review or to a court of 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 Street address (number and street, city, state, and ZIP code) Telephone number E-mail address

(

)

Hereby petitions for exemption from taxation of the following described real estate and improvements and / or personal property: LAND Legal Description $ Assessed Value 1. 2. 3.
Personal property assessment $ Date of assessment March 1, 20 _______ Township / Taxing District located in DLGF taxing district number

IMPROVEMENTS (BUILDINGS) Description of Improvements (Name or describe each building) $ $ $

Assessed Value

Parcel Number

Key number

Upon what uses or purpose do you base the claim for exemption? Charitable - pursuant to I.C. 6-1.1-10-16. Educational - pursuant to I.C. 6-1.1-10-16. Religious - pursuant to I.C. 6-1.1-10-16. Other - (cite the specific law(s) under which the exemption is claimed)

What percentage do you claim should be exempt on the value of:
Land and lots Improvements (buildings) 1. Personal property 2. 3.

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 Summary of income and expenditure If Otherbox is checked above - the specific statute under which the exemption is claimed must be cited.

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 persons 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 organizations exempt purpose.
Signature of authorized representative Title Date signed (month, day, year)

Page 1 of 5

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 I.C. 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 7b. State the address of the entity.

7a. State the name of such 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 claimed exempt use? (If No, skip to 2.) Yes 1b. State specifically what rooms or areas are used by such individuals or groups. 1a. Name such individuals or groups.

No
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.

Page 2 of 5

REQUIRED INFORMATION (continued)
III. OTHER INFORMATION (continued)
3. Do the individuals whose activities are related to the exempt purpose ever use rooms or areas for activities not directly related to the basis for the claimed exemption? (If No, skip to 4.) 3b. State specifically what rooms or areas are so used. 4. Are fees ever charged to those who make use of rooms or areas? (If No, skip to 5.) Yes 4b. State how often such fees are charged. 4e. For what purpose is the revenue derived from such fee used? 6. Are any rooms or areas ever used by any income generating activity? (If No, skip to 7.) Yes 6b. State specifically where it occurs. 6c. State specifically how often it occurs. 7. Are food or items of any sort ever sold? (If No, skip to 8.) 7b. State specifically where it is sold. 7c. State specifically how often such sales occur. 8. Are dances, dinners or other social functions ever held on the property for which the exemption is claimed? (If No, skip to 9.) Yes 8b. State specifically where it occurs. 8c. State specifically how often it occurs. 9. Are goods, crops, or food of any sort ever made, grown, or produced on the property? Yes 8d. State who conducts such activity. 9a. If so, specifically describe such goods, crops or food. 7d. State specifically who makes such sales. 8a. State the activity. 7a. State what is sold. 6d. State who conducts such activity. 6a. State the activity. 3a. State who makes such use of rooms or areas.

Yes

No
3c. State specifically how often such rooms or areas are to be used.

4a. State the uses for which such fees are charged.

No
4c. State who is charged such fee. 4d. State what fee is charged. 5. How many individuals participate in the exempt activities?

No

Yes

No

No

No
9c. State specifically where such goods, crops or food is made, grown or produced. 9e. State the dollar value of each good, crop or food made, grown or produced.

9b. State specifically the number or amount of goods, crops or food made, grown or produced. 9d. State specifically who makes, grows, or produces such goods, crops or food.

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

Page 3 of 5

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

DESCRIPTION
Land and lots 1. 2. 3. Improvements (Buildings) 1. 2. 3. Personal property 1. 2. 3. $ $

ASSESSED VALUE
$

EXEMPTION ALLOWED PERCENT
$

EXEMPTION NOT ALLOWED PERCENT
$

ASSESSED VALUE

ASSESSED VALUE

$

$

$

$

TOTALS
Date application filed

$

0.00

0.00

$

0.00
Yes

0.00

$

0.00
No No

Was the entire application completely filled out (pages 1, 2, and 3)?

Was any information not in writing or on the form presented to the County PTABOA? State who presented the information and summarize the information provided.

Yes (if yes complete next line)

Did the County PTABOA consider the actual use of the property? What is the percentage of actual exempt use of each room, area, or building for which the exemption is claimed?

Yes

No

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)

Page 4 of 5

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 before May 15th of assessment year (the year prior to the tax billing date). An application must be filed every even numbered year, unless the exempt property meets the definition under 6-1.1-11-4(d). However, an application must be filed in any other year if the property was not exempted in the immediately preceding year. An application should be filed in any year in which an appeal to the Indiana Board of Tax Review or to a court of 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. 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. The appeal must be filed with the County Assessor on Form 132, prescribed by the Indiana Board of Tax Review. Before August 2nd, the County Assessor will forward to the Department of Local Government Finance the duplicate copy of each approved application. The Department is required to 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. 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.

Page 5 of 5