State Form 53854 - Single Return - Business Tangible Personal Property

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January 1, 2017

SINGLE RETURN -

FORM 103-SR

BUSINESS TANGIBLE PERSONAL PROPERTY

For assessor's use only

PRIVACY NOTICE

State Form 53854 (R8 / 11-16)

This form contains

Prescribed by the Department of Local Government Finance

information confidential

pursuant to IC 6-1.1-35-9.

NOTE: For taxpayers with less than $20,000 cost to report within the county, legislation was passed in 2015 which exempts this property. If you are

declaring this exemption, check this box, enter the total acquisition cost of your personal property in the county, and complete only sections I and IV of this

form. If you are declaring this exemption through this form, you do not need to file a Form 104-SR.

$ ________________________

RETURN THIS FORM TO THE APPLICABLE ASSESSOR BY MAY 15, 2017.

An exemption granted under IC 6-1.1-10 or any other statute supersedes this exemption. In other words, a taxpayer whose personal property is exempt

because the taxpayer applied for and was granted an exemption by the county must follow all applicable procedures for the approved exemption, which

may include fully completing the personal property return.

SECTION I

Name of taxpayer

Name to which assessment and tax notice are to be mailed

County

Address to which assessment and tax notice are to be mailed (number and street, city, state, and ZIP code)

Federal Identification Number **

Nature of business

NAICS code number *

SECTION II

1. Federal income tax year ends

2. Name under which federal return is filed

3. Location of accounting records

4. Form of business

Partnership or Joint Venture

Sole Proprietorship

Corporation

Estate or Trust

Other (describe) _________________________________________

5. Did you own, hold, possess, or control any leased, rented, or

If yes, file Form 103-N or Form 103-O (see 50 IAC 4.2-8-3 and 4).

other depreciable personal property on January 1?

Failure to properly disclose lease information may result in a double assessment.

Yes

SECTION III

Additional locations

LOCATION SUMMARY:

List each location where you own, hold, possess or control personal property subject to

assessment. Include the complete address (street address) for each location. Assign a

Page ________ of ________

location number to each separate location. Attach additional sheets if necessary.

LOCATION

DLGF TAXING

NAME UNDER WHICH BUSINESS IS CONDUCTED (if different than above)

TOWNSHIP

NUMBER

DISTRICT NUMBER

AND SPECIFIC STREET ADDRESS (number and street, city, state, and ZIP code)

SUMMARY

LOCATION NUMBER

____________

(Round all numbers to nearest ten dollars.)

SCHEDULE A - PERSONAL PROPERTY

FINAL ASSESSED VALUE

SUMMARY

LOCATION NUMBER

____________

(Round all numbers to nearest ten dollars.)

SCHEDULE A - PERSONAL PROPERTY

FINAL ASSESSED VALUE

* NAICS - North American Industry Classification System - A complete list of codes may be found at For further information, contact the

Assessor (contact information is available at ).

** An individual using his/her Social Security Number as the Federal Identification Number is only required to provide the last four (4) digits of that number. IC 4-1-10-3

SECTION IV

SIGNATURE AND VERIFICATION

Under penalties of perjury, I hereby certify that this return (including accompanying schedules and statements), to the best of my knowledge and belief,

is true, correct and complete; reports all tangible personal property subject to taxation, owned, held, possessed or controlled by the named taxpayer in

the stated township or taxing district on the assessment date of this return, as required by law; and is prepared in accordance with IC 6-1.1 et seq., as

amended, and regulations promulgated with respect thereto.

Signature of authorized person

Date (month, day, year)

Printed name of authorized person

Title

T elephone number

(

)

Signature of person preparing return, if different than authorized person

Name and contact information of preparer

Page ______ of ______