Free 47336.FH11 - Indiana

SCHEDULE A-4 -- WATER POLLUTION CONTROL EQUIPMENT
State Form 47336 (R / 12-04)

INSTRUCTIONS:

1. 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). 2. Report below all personal property employed predominately in the operation of an industrial water treatment system for elimination of water pollution caused by industrial wastes. The property must be approved by the IDEM to qualify for the exemption. 3. Attach additional schedules if necessary. WATER POLLUTION CONTROL EQUIPMENT IN SERVICE P.S.C.I. Description of Property Account Number Net Tax Value (Federal Cost Less Tax Depr.)

Year Acqrd.

Location of Property

Federal Tax Cost

TOTALS - CARRY THE TOTAL COST TO SCHEDULE A, LINE 17
WATER POLLUTION CONTROL EQUIPMENT IN CIP P.S.C.I. Account Description of Property Number Net Tax Value (Federal Cost Less Tax Depr.)

Year Acqrd.

Location of Property

Federal Tax Cost

TOTAL - CARRY TO SCHEDULE A-1 Under penalties of perjury, I hereby certify that this schedule, 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 signed (month, day, year)