Connecticut Confidential Report For Personal Property Form

Connecticut Confidential Report For Personal Property Form - 2005 Page 2

LES S EE'S REP ORT OF P ERS ONAL P ROP ERTY

AS S ES S MENT DATE: OCTOBER 1, 2005

All le a s e d ma chine ry a nd e quipme nt in your pos s e s s ion a s of the a s s e s s me nt da te , mus t be include d in this re port.

FAILURE TO FILE this re port, in the form a nd ma nne r a s he re in pre s cribe d, s ha ll re s ult in a pre s umption of your owne rs hip,

a nd s ubs e que nt ta x lia bility, of a ny ite ms of le a s e d pe rs ona l prope rty in your pos s e s s ion.

Le s s e e 's Name

Name of Bus ine s s

Bus ine s s Addre s s , Numbe r, S tre e t, and City or Town

Le s s e e 's Mailing Addre s s (If diffe re nt than prope rty location)

Te le phone No.

Owne r's Name and Addre s s

Ite m De s cription

Mode l #

Ye ar

Le as e Te rm

Monthly

Es timate d

Type

Mfg-

(Start/End)

Re nt

Cos t

We re any le as e d ite ms in your pos s e s s ion on 10/1/04, dis pos e d of prior to 10/1/05?

YES

If ye s , e nte r de s cription, date of dis pos al and trans fe re e .

LES S EE'S AFFIDAVIT

I do he re by de clare unde r pe nalty of fals e s tate m e nt that the fore going lis t, according to the be s t of m y knowle dge ,

re m e m brance and be lie f is a true s tate m e nt of all le as e d prope rty which was in pos s e s s ion as of Octobe r 1, 2005.

and Dated at

da y of

Signed

this

,2005.

Connecticut Confidential Report For Personal Property Form - 2005 Page 2