Form 800 - Business Equipment Tax Reimbursement Application

800

BUSINESS EQUIPMENT TAX

Form

REIMBURSEMENT

*0510700*

APPLICATION

2005

(for eligible personal property taxes paid in 2004)

Application must be filed no

Check if applicant is a:

Corporation

LLC

later than January 3, 2006.

Partnership

Sole Proprietor

If applicant is a corporation, partnership or LLC, enter federal ID number .....................

Business Name

If applicant is a sole proprietor, enter Social Security number ..........................................

Your First Name

Initial

Your Last Name

Mailing Address

City/Town

State

Zip

1. Consolidated application:

YES

(If yes, complete lines 2, 4, 5, 6, 8 and 9. Lines 5, 6, 8 and 9 must reflect the

total from all municipalities. Do not complete lines 3 and 7.)

2. Business Code

(If no, complete lines 2 through 9.)

3. Municipal Code

4a. Check this box if business was started

4b. Check this box if the business also receives

on or after April 1, 1995

reimbursement under a TIF program

Enter the following information for property tax payments made in calendar year 2004 based on the April 1, 2003 and/or April 1,

2004 assessments. See Instructions.

Assessed April 1, 2003

Assessed April 1, 2004

5. Original cost of eligible property .......... 5a

6. Assessed Value ................................... 6a

7. Property Tax Rate ................................ 7a mils

7b mils

8. Requested Reimbursement

................ 8a

9. Total Reimbursement. Line 8a plus line 8b or Total Consolidation Schedule ...... 9

Tax paid on eligible property only, taking into account any early payment discounts, but exclusive of any interest, penalties or any

other charges. Proof of tax payment and a copy of the tax bill must be included with your claim. Requested reimbursement must

exclude any portion of the property tax payments related to property not eligible for the program. See instructions on page 4.

Applicant (or business owner) signature: Under penalties of perjury, I declare that I have examined this application and

accompanying schedules and statements and, to the best of my knowledge and belief, they are true, correct and complete.

Declaration of preparer (other than applicant) is based on all the information of which the preparer has any knowledge.

Telephone

Applicant ____________________________ Date

Number

(or business officer)

Preparer

Preparer ____________________________ Date

ID Number

Preparer Telephone Number

office use only

, 2005

EVISED

Form 800 - Business Equipment Tax Reimbursement Application - 2005

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