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Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Division of Historic Preservation and Archaeology | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
 | APPLICATION TO CLASSIFY LAND AS CEMETERY LAND |  |  |  |  |  | 402 W. Washington St., W274, Indianapolis, IN  46204-2739
 |  |  |  |  |  |  | [PHONE]; FAX [PHONE]; [EMAIL]
 | State Form 50948 (6-02)
Instructions:
1. Read all instructions before completing application.
2. Please type or print clearly in black ink.
3. Classification cannot be made unless a completed application form has been received.
NOTE:  A copy of this form will be provided to the County Assessor and County Recorder.
BOX #1 |  |  |  |  |  |  |  |  |  | Property Information
[NAME]
Property Address (Number and Street)
City |  |  |  |  | County |  |  | Zip Code
BOX #2 |  |  |  |  |  |  |  |  |  | Cemetery Owner
Name |  |  |  |  |  |  | Daytime Telephone Number
Address (Number and Street)
City |  |  |  | County |  |  | State |  | Zip Code
E-mail Address (optional)
BOX #3 |  |  |  |  |  |  |  |  |  | Landowner Certification
 |  | Is there another dwelling or other building situated on this parcel?
 |  | Is this land being grazed by a domestic animal?
Land Owner Signature |  |  |  |  |  |  | Date
BOX #4 |  | FOR OFFICE USE ONLY
The Division of Historic Preservation and Archaeology has reviewed the Application for the above named property and hereby determines:
 | This cemetery is listed in the Indiana Cemetery and Burial Grounds Registry.
 | This cemetery is listed in the Indiana Cemetery and Burial Grounds Registry.
 | Plats referred to in IC 6-1.1-6.8 are included with application.
 | Assessment by county assessor attached.
 | Signatures attached.
DHPA Authorized Signature |  |  |  |  |  |  | Date
State Form 50948 (6-02)
APPLICATION TO CLASSIFY LAND AS CEMETERY LAND
INSTRUCTIONS
This form and copies thereof will provide documentation of application and certification for the RECLASSIFICATION OF LAND AS CEMETERY LAND.  Some portions of the form provide information from the land owner, while determination of compliance with the statutory requirements are to be made by staff of the Division of Historic Preservation and Archaeology (DHPA). The applicant should complete only those sections which request information from the landowner. All requested information should be typed or printed clearly in black ink.
BOX #1 - Property Information: This portion of the application is to be completed by the applicant. Property Name should provide the historical name associated with the cemetery, if such is known (for example, Crown Hill Cemetery or Smith Family Burial Ground).  If no historical name is known, the name of the present property owner or the property address may be placed here. The remainder of this box requests common location information, street address, city, county and zip code.
BOX #2 - Landowner Contact: This portion of the application is to be completed by the applicant.  Provide the name, mailing address, telephone number and e-mail address (optional) for the owner of the cemetery.
BOX #3 - Landowner Certification: This portion of the application is to be completed by the applicant to certify that the land meets the requirements of eligibility for  reclassification.  THE OWNER MUST SIGN THIS SECTION OF THE APPLICATION SIGNIFYING THAT THE INFORMATION PROVIDED IS [NAME] AND CORRECT.
BOX #4 - DO NOT WRITE IN THIS BOX. This portion of the application is to be completed by the DHPA . Here, the Division staff certifies that the property meets the statutory requirements of eligibility for the reclassification.  Attached with the application the landowner must supply the survey completed by the registered surveyor, the reassessment made by the county assessor, and the signatures of the owner, the registered land surveyor, and the county assessor.
Items required by IC 6-1.1-6.8-6: A person who wishes to have a parcel of land classified as cemetery land must have it surveyed by a registered land surveyor.  The surveyor shall make the survey by metes and bounds and locate the parcel with reference to some established corner.  In addition, the surveyor shall identify the parcel by section, township, range and county references.  The surveyor shall prepare plats of the parcel in ink.