Declaration Of Personal Property - Short Form - Connecticut

’

Lessee’s Name ________________________________________

ESSEE

ISTING

EPORT

Pursuant to Connecticut General Statutes §12-

57a all leased, borrowed, consigned, loaned, rented, or stored personal property not owned by you but in your possession as of the assessment date must be included on this

form. Failure to declare, in the form and manner as herein prescribed, shall result in the presumption of ownership and subsequent tax liability plus penalties. Property you do

not lease that may be in your possession and must be reported includes (but is not limited to) dumpsters, gas/propane tanks, vending machines, water coolers, coffee machines.

COPY AND ATTACH ADDITIONAL SHEETS IF NEEDED

Yes No

Did you dispose of any leased items that were in your possession on

October 1, 2008? If yes, enter a description of the property and the

date of disposition in the space to the right.

Did you acquire any of the leased items that were in your possession

on October 1, 2008? If yes, indicate previous lessor, item(s) and

date(s) acquired in the space to the right.

Is the cost of any of the equipment listed below declared anywhere else on this declaration? If yes, note year in the ‘Year Included’ row and list

cost in the ‘Acquisition Cost’ row.

Lease #1

Lease #2

Lease #3

Name of Lessor

Lessor’s address

Lease Number

Item description / Model #

Serial #

Year of manufacture

Yes

Capital Lease

Lease Term – Beginning/End

Monthly rent

Acquisition Cost

Year Included

ECLARATION OF

ERSONAL

ROPERTY

FFIDAVIT

(

)

HIS FORM MUST BE SIGNED

AND IN SOME CASES WITNESSED

BEFORE IT MAY BE FILED WITH THE

SSESSOR

–

IMPROPERLY SIGNED DECLARATIONS REQUIRE A 25% PENALTY

VOID

ENALTY

OMPLETE

ECTION

Section A

OWNER 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; 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 as per Connecticut General Statutes

§12-49.

CHECK ONE

OWNER

PARTNER

CORPORATE OFFICER

MEMBER

Dated

Signature

Signature/Title

Print or type name

Section B

AGENT I DO HEREBY declare under oath that I have been duly appointed agent for the owner of the property listed herein 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

Signature

Dated

Agent’s Signature /Title

Print or type agent’s name

AGENT SIGNATURE MUST BE WITNESSED

Witness of agent’s sworn statement

Subscribed and sworn to before me -

Dated

Circle one: Assessor or staff member, Town Clerk, Justice of the Peace, Notary or Commissioner of Superior

Court

The Personal Property Declaration must be signed above and delivered to the Assessor or postmarked (as defined in C.G.S. Sec. 1-

2a) by Monday, November 2, 2009 – a 25% Penalty required for failure to file as required.

Declaration Of Personal Property - Short Form - Connecticut - 2009 Page 4

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