Indiana Petition for Waiver of Penalties Against a Taxpayer or Taxpayers Representative on Real or Personal Property

Petition for Waiver of Penalties Against a Taxpayer or Taxpayers Representative on Real or Personal Property
53165.FH11
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PETITION FOR WAIVER OF PENALTIES AGAINST A TAXPAYER OR
TAXPAYER’S REPRESENTATIVE ON REAL OR PERSONAL PROPERTY

FORM 137 TP

State Form 53165 (R3 / 12-10)
Prescribed by the Department of Local Government Finance

INSTRUCTIONS:
1. This form is to be used by a person who is seeking a waiver of the penalty of real or personal property tax liability.
2. This form is to be filed with the county treasurer of the county in which the property is located within thirty (30) days after the due date of the installment
subject to penalty.
3. The taxpayer or taxpayer’s representative must submit proof that during the seven (7) day period before the installment due date that an immediate family
member who resided in the taxpayer’s home had passed away. An immediate family member would include a spouse, child, stepchild, parent, stepparent,
or adoptive relationships.
4. A separate form must be filed on each tax parcel.
5. If insufficient space exists to complete any part of this form, attachments are acceptable.
6. This waiver of penalty is subject to IC 6-1.1-37-10.7.
7. A taxpayer may appeal a determination of the county treasurer to deny a penalty waiver by filing notice in writing with the treasurer not more than forty-five
(45) days after the treasurer gives notice of the determination. The appeal would be processed and determined under IC 6-1.1-15.
SECTION 1

PROPERTY INFORMATION

Address of property (number and street, city, state, and ZIP code)
County

Township

DLGF Taxing District number

Name of taxpayer

Parcel number (file a separate form for each parcel)

Name of contact person

Mailing address of contact person or taxpayer’s representative (number and street, city, state, and ZIP code)
Telephone number

(

Fax number

)

(

E-mail address (optional)

)

SECTION 2

PETITIONER INFORMATION

Name of petitioner
Mailing address of petitioner (number and street, city, state, and ZIP code)
Telephone number

Fax number

Taxpayer’s relationship to deceased family member

Deceased member resided in taxpayer’s home?

(

)

(

E-mail address (optional)

)
Yes

Date of taxpayer’s / family member’s death (month, day, year)

No

Provide written proof of the taxpayer’s / family member’s death (i.e. death certificate or published obituary)

SECTION 3
1
ASSESSMENT
YEAR

2

AMOUNT OF DELINQUENT TAX LIABILITY (obtain from County Auditor or County Treasurer)
3
4
5
6
7

PAYMENT
YEAR

AMOUNT OF
DELINQUENT
PROPERTY TAXES

AMOUNT OF
PENALTIES

AMOUNT OF
INTEREST

COSTS

AMOUNT OF
SPECIAL
ASSESSMENTS

8

9

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

REQUESTED
AMOUNT OF
WAIVER *

* Requested amount of waiver cannot exceed column 4.

SECTION 4

CERTIFICATION

The below petitioner seeks a waiver of the total delinquent penalty on real and/or personal property shown in Section 3 of this petition.
I hereby certify that the above representations are true and correct.
Authorized signature of petitioner or taxpayer’s representative

Date signed (month, day, year)
Title

Printed name of signatory

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

DETERMINATION OF THE COUNTY TREASURER
I, treasurer of the county named above, have made the following determination on this petition. If you do not agree with it, you may file a notice in writing
with me within forty-five (45) days of the mailing of this determination to initiate an appeal which would be processed and determined under IC 6-1.1-15.
Signature of Approval by County Treasurer
Approved amount of waiver

Signature of Denial by County Treasurer

Date (month, day, year)

Comment / Explanation:

INSTRUCTIONS TO COUNTY TREASURER:
1. Determine whether this petition qualifies under the provisions of IC 6-1.1-37-10.7.
2. Provide a copy of your determination to the taxpayer or the taxpayer’s representative by mail within thirty (30) days of the filing of the petition.
3. Provide a copy of your determination to the County Auditor.
4. If the taxpayer or the taxpayer’s representative desires to appeal this determination, accept and process it in accordance with IC 6-1.1-15.