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SINGLE RETURN BUSINESS TANGIBLE PERSONAL PROPERTY
State Form 53854 (2-09)

FORM 103-SR
PRIVACY NOTICE
The records in this series are confidential according to IC 6.1-1-35-9.

March 1, 2009
For assessor's use only

Prescribed by the Department of Local Government Finance INSTRUCTIONS:

PLEASE TYPE or PRINT. This form must be filed with the County Assessor no later than May 15. This form is for use by taxpayers who have personal property in more than one (1) township in a county and the total assessed value of the personal property in the county is less than one million five hundred thousand dollars ($1,500,000). If you are claiming any special adjustments such as equipment not placed in service, special tooling, permanently retired equipment, or abnormal obsolescence, file Form 103 Long.

The county assessor may refuse to accept a single personal property tax return that does not have attached to it a schedule listing, by township, all the personal property of the taxpayer and the assessed value of the property for each taxing district as required. [IC 6-1.1-3-7 (f)] T axpayers who are not eligible to file Form 103-SR, or who wish to use a substitute return form, may seek approval from the Department of Local Government Finance to use an unprescribed form. Approval to use an unprescribed return form must be obtained in advance from the Department of Local Government Finance. [50 IAC 4.2-2-9(c)]
Name of taxpayer Name to which assessment and tax notice is to be mailed Address to which assessment and tax notice is to be mailed (number and street, city, state, and ZIP code) Nature of business 1. Federal Income Tax year ends 4. Form of business 2. Name under which federal return is filed County Federal Identification number NAICS code number * 3. Location of accounting records

Partnership or Joint Venture Estate or Trust Yes

Sole Proprietorship Corporation Other (describe) _________________________________________ No If yes, file Form 103-N or Form 103-O (see 50 IAC 4.2-8-3 and 4). Failure to properly disclose lease information may result in a double assessment.
Additional locations

5. Did you own, hold, possess, or control any leased, rented, or other depreciable personal property on March 1?

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 location number to each separate location. Attach additional sheets if necessary. DLGF TAXING DISTRICT NUMBER

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LOCATION NUMBER

TOWNSHIP

NAME UNDER WHICH BUSINESS IS CONDUCTED (if different than above) AND SPECIFIC STREET ADDRESS (number and street, city, state, and ZIP code)

SUMMARY (Round all numbers to nearest ten dollars) SCHEDULE A - PERSONAL PROPERTY DEDUCTION PER FORM PPID-1 (Investment Deduction) FINAL ASSESSED VALUE

LOCATION NUMBER ____________ + = $ $ $ $ $ $

LOCATION NUMBER ____________ $ $ $

LOCATION NUMBER ____________

0.00

0.00

0.00

LOCATION NUMBER LOCATION NUMBER SUMMARY LOCATION NUMBER ____________ ____________ ____________ (Round all numbers to nearest ten dollars) $ SCHEDULE A - PERSONAL PROPERTY + $ $ $ DEDUCTION PER FORM PPID-1 (Investment Deduction) $ $ FINAL ASSESSED VALUE = $ 0.00 $ 0.00 $ 0.00 * NAICS - North American Industry Classification System - complete list of codes may be found at www.census.gov . The Indiana Code (IC) and Indiana Administrative Code (IAC) may be found on-line at the DLGF website - www.in.gov/dlgf . For further questions contact the Township Assessor (available on the DLGF website). 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 Printed name of authorized person Title Date (month, day, year) T elephone number

(

)

Signature of person preparing return based on all information of which he has any knowledge

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SCHEDULE A FOR FORM 103-SR
Part of State Form 53854 (2-09)

MARCH 1, 2009

INSTRUCTIONS: NOTE:

1. Assign a location number to each separate location within a county. 2. If more than one page is necessary, attach additional forms and indicate on front of Form 103-SR.

The location numbers shown below must correspond with the locations and location numbers shown on the front of this form (Form 103-SR) and on the reverse side of Form 104-SR. DEPRECIABLE PERSONAL PROPERTY # # COLUMN B TTV COLUMN A TOTAL COST COLUMN B TTV

LOCATION NUMBER TAXING DISTRICT NUMBER LINE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 YEAR OF ACQUISITION From to 3-1-09 3-2-08 to 3-1-09 3-2-07 to 3-1-08 3-2-06 to 3-1-07 3-2-05 to 3-1-06 3-2-04 to 3-1-05 3-2-03 to 3-1-04 3-2-02 to 3-1-03 3-2-01 to 3-1-02 3-2-00 to 3-1-01 3-2-99 to 3-1-00 Prior to 3-2-99 TOTALS 30% of line 13, Column A TTV% 40% 40% 60% 55% 45% 37% 30% 25% 20% 16% 12% 10%

# #

# # COLUMN A TOTAL COST COLUMN B TTV

COLUMN A TOTAL COST

Line 15 must be the greater of Line 13, Column B or Line 14 [see 50 IAC 4.2-4-9] Total True Tax Value (TTV)of Depreciable Personal Property (to Summary on Form 103-SR) DEPRECIABLE PERSONAL PROPERTY LOCATION NUMBER TAXING DISTRICT NUMBER LINE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 YEAR OF ACQUISITION From TTV% # # COLUMN A TOTAL COST COLUMN B TTV # # COLUMN A TOTAL COST COLUMN B TTV # # COLUMN A TOTAL COST COLUMN B TTV

to 3-1-09 40% 3-2-08 to 3-1-09 40% 3-2-07 to 3-1-08 60% 3-2-06 to 3-1-07 55% 3-2-05 to 3-1-06 45% 3-2-04 to 3-1-05 37% 3-2-03 to 3-1-04 30% 3-2-02 to 3-1-03 25% 3-2-01 to 3-1-02 20% 3-2-00 to 3-1-01 16% 3-2-99 to 3-1-00 12% Prior to 3-2-99 10% TOTALS 30% of line 13, Column A Line 15 must be the greater of Line 13, Column B or Line 14 [see 50 IAC 4.2-4-9] Total True Tax Value (TTV)of Depreciable Personal Property (to Summary on Form 103-SR)

Election to report cost of Depreciable Assets by Federal tax year.

Yes

No

Election available only when federal tax year ends December 31 or January 31 [see 50 IAC 4.2-4-6(c)]. If taxpayer elects to report cost above on federal tax year basis, assets acquired from the prior federal tax year end to March 1 are to be reported on the first line of the appropriate pool.

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