Personal Property Declaration Form (Page 5 of 5) in pdf

Code 9, 11, and 14 Property -- Exemptions Listing -- Affidavit

Regardless of Past Practices this Form Must be Used and No Extensions Will be Granted.

Assessment date October 1, 2004

List/Account #:

Required return date November 1, 2004

Owner’s Name:

DBA: 0

Location (street & number): 0

Taxable Property

- Do not include real estate or Connecticut registered motor vehicles.

#9 Motor vehicles Unregistered motor vehicles

Code

Assessments

Year

Make

Model

Identification No.

Length

Weight

Purchase Price

Date

Value

#11 Horses, ponies and thoroughbreds

Breed

Age

Registered

Sex

Quality: Breeding/Show/Pleasure

Value

#11

#14 Mobile Manufactured Homes -- if not currently assessed as real estate

Year

Make

Model

Length

Width

Bedrooms

Baths

Value

#14

Net Depreciated

Code

Property Description -

Value

#10

Machinery & Equipment

#10

#12

Commercial Fishing Apparatus

#12

Newly Acquired Manufacturing Machinery & Equipment

#13

on or after 10/2/94

#13

#16

Furniture & Fixtures

#16

#17

Farm Machinery

#17

#18

Farming Tools

#18

#19

Mechanics Tools

#19

#20

Electronic Data Processing Equipment

#20

#21

Telecommunications Equipment

#21

#22

Cables, conduits, pipes, poles, towers, underground mains, wires, etc.,

#22

#23

Expensed Supplies

#23

#24

Other

#24

Check box adjacent to the exemption you are claiming:

Mechanic’s Tools - $500 valuel

Horses/ponies $1000 assessment per animal

Commercial Fishing Apparatus - $500 value

Farming Tools - $500 value

All of the following exemptions require a separate application and/or certificate to be filed with the Assessor by November 1

Water Pollution or Air Pollution control equipment - Connecticut DEP certificate required - provide copy

Farm Machinery $100,000 value - Exemption application M-28 required annually by Oct. 31

Distressed Municipality/Enterprise Zone/Enterprise Corridor Zone - Exemption application M-55 required annually

New manufacturing machinery and equipment claimed under Code #13 - Exemption application M-65 required annually

Affidavit -

This form must be signed (and in some cases witnessed) before it may be filed with the Assessor. Avoid Penalty - Notarize list signed by agent.

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, 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.

Owner's Signature

Date

Type name here:

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 list for him in accord with the provisions of §12-50 C.G.S.

Agent's Signature

Date

Type name here:

Witness of agent’s sworn statement

Subscribed and sworn to before me -

Date

Assessor or staff member, Town Clerk, Justice of the Peace, Notary or Commissioner of Superior Court

Assessor’s Final Assessment Totals

Total Assessment -- all codes

#25 - Penalty for failure to file as required by statute -- 25% of assessment

#25