Form 104-Sr - Single Return Business Tangible Personal Property(2015)
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SINGLE RETURN
JANUARY 1, 20___
FORM 104-SR
BUSINESS TANGIBLE PERSONAL PROPERTY
For assessor's use only
State Form 53855 (R3 / 11-15)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS:
1. This form must accompany a Single Return Business Tangible Personal Property Form (Form 103-SR)
2. This form must be filed with the County Assessor not later than May 15 unless an extension is granted in writing.
Name of taxpayer (please type or print)
County
Name under which business is conducted
NAICS code number*
Address where property is located (number and street, city, state, and ZIP code)
Nature of business
Name to which assessment and tax notice are to be mailed (if different than above)
Address to which assessment and tax notice are to be mailed (number and street, city, state, and ZIP code) (if different than above)
FILING REQUIREMENTS
All taxpayers filing Form 103-SR must complete Form 104-SR. Taxpayers filing Forms 102, 103-Long or 103-Short must complete Form 104.
ADDITIONAL RETURN REQUIREMENTS
A copy of Form 103-SR and Form 104-SR, for each township listed on the return, must be filed with the County Assessor.
Were expenditures made since the last assessment date for improvements on any real estate owned, possessed, or occupied by the taxpayer in the
township wherein this return is filed?
Yes
No
(If Yes, attach a statement setting forth: name of owner, location of real estate and explaining nature, cost, date construction or improvements were
begun and date construction was completed. If not completed as of January 1, state the percentage completed at that time.) [IC 6-1.1-5-13]
SUMMARY
LOCATION NUMBER
LOCATION NUMBER
LOCATION NUMBER
(Round all numbers to nearest ten dollars)
____________
____________
____________
SCHEDULE A - PERSONAL PROPERTY
+
$
$
$
FINAL ASSESSED VALUE
=
$
$
$
SUMMARY
LOCATION NUMBER
LOCATION NUMBER
LOCATION NUMBER
(Round all numbers to nearest ten dollars)
____________
____________
____________
SCHEDULE A - PERSONAL PROPERTY
+
$
$
$
FINAL ASSESSED VALUE
=
$
$
$
* NAICS - North American Industry Classification System - complete list of codes may be found at For further information, contact the
Assessor (contact information available on the DLGF website, ).
Page ______ of ______
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