2004 Personal Property Declaration Page 6
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6List or Account #:
Assessment date October 1, 2004
Required return date November 1, 2004
Owner’s Name:
DBA:
A
B
C
S
B
FFIDAVIT OF
USINESS
LOSING OR
ALE OF
USINESS
I
of
at
Business owners name
Business Name (if applicable)
Street location of business name shown
With regards to said business do so certify that on
Said business was (indicate which one by circling):
Date
S
:
OLD TO
Name
Address
T
:
Attach Bill of Sale or Letter of dissolution to this form and return with this affidavit to the Assessor’s office
ERMINATED
The signer is made aware that the penalty for making a false affidavit is a $500.00 fine or imprisonment for one year or both.
Signature
Print name
A
- T
(
)
A
.
FFIDAVIT
HIS FORM MUST BE SIGNED
AND IN SOME CASES WITNESSED
BEFORE IT MAY BE FILED WITH THE
SSESSOR
A
P
- N
P
P
D
.
VOID
ENALTY
OTARIZE
ERSONAL
ROPERTY
ECLARATION SIGNED BY AGENT
I DO HEREBY declare under penalty of perjury 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.
Owner’s
Dated
Signature
*Owner’s Signature (print owner’s name on line below)*
*Print or type owner’s name*
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
Dated
Signature
Witness of agent’s sworn
statement subscribed and
sworn to before me -
Dated
Assessor or staff member, Town Clerk, Justice of the Peace, Notary or
Commissioner of Superior Court
Page 6
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