Declaration Of Personal Property - Short Form - Connecticut

COPY AND ATTACH ADDITIONAL SHEETS IF NEEDED

Yes No

Did you dispose of any leased items that were in your possession on

October 1, 2003? If yes, enter a description of the property and the

date of disposition in the space to the right.

Did you acquire any of the leased items that were in your possession

on October 1, 2003? If yes, indicate previous lessor, item(s) and

date(s) acquired in the space to the right.

Is the cost of any of the equipment listed below declared anywhere else on this declaration? If yes, note year in the ‘Year Included’ row and list

cost in the ‘Acquisition Cost’ row.

Lease #1

Lease #2

Lease #3

Name of Lessor

Lessor’s address

Lease Number

Item description / Model #

Serial #

Year of manufacture

Yes

Capital Lease

Lease Term – Beginning/End

Monthly rent

Acquisition Cost

Year Included

, H

ARM

ACHINERY

ORSES OR

ONIES

M-28 Revised August 98

Approved by Commissioner of Agriculture

This application for exemption on all farm machinery, except motor vehicles as defined in Section 14-1, to the value of $100,000, ponies or horses which are actually and

exclusively used in farming, within the provisions of Section 12-91 of the General Statutes as amended MUST BE FILED ANNUALLY BY OCTOBER 31ST with the

assessor or board of assessors of the municipality in which the property is located. Failure to file this application within the time limit prescribed shall be considered a waiver

of the right to such exemption for the assessment year.

Have you filed, or do you intend to file, any application for exemption as provided under the above statute, in this or any other town or city, as trustee, as an

YES NO

individual farmer, or as a member of a group of farmers, partnership or family corporation, other than under the ownership contained in this application?

Do you derive at least $15,000 in gross sales, or did you incur at least $15,000 in expenses related to such farming operation during the previous calendar year?

Are the horses and ponies, and/or farm machinery kept within the State of Connecticut?

If yes, list town(s):

I DO HEREBY declare in accordance with § 12-91 of the Connecticut General Statutes under penalty of perjury that the statements herein made by me are true according to

the best of my knowledge and belief.

Date:

Signed: (owner(s) or trustee(s))

Subscribed and Sworn to before me:

My commission expires

Date:

ECLARATION OF

ERSONAL

ROPERTY

FFIDAVIT

(

)

HIS FORM MUST BE SIGNED

AND IN SOME CASES WITNESSED

BEFORE IT MAY BE FILED WITH THE

SSESSOR

VOID

ENALTY

OTARIZE

ERSONAL

ROPERTY

ECLARATION SIGNED BY AGENT

OWNER I

DO HEREBY declare under penalty of false statement that all sections of this declaration have been completed according to the best of my knowledge, remembrance,

and belief; that it is a true statement of all my personal property liable to taxation; and that I have not conveyed or temporarily disposed of any estate for the purpose of evading the

laws relating to the assessment and collection of taxes as per Connecticut General Statutes

12-49.

Owner’s

Signature

Dated

Owner’s Signature (print owner’s name on line below)

Print or type owner’s name

CORPORATE OFFICER OR AGENT

I DO HEREBY declare under oath that I have been duly appointed agent for the owner of the property listed above and that I have full

authority and knowledge sufficient to file a proper declaration for him in accord with the provisions of

12-50 C.G.S.

Agent’s