L
’
L
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Lessee’s Name ________________________________________
ESSEE
S
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, 2009? 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, 2009? 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
No
Yes
No
Yes
No
Capital Lease
Lease Term – Beginning/End
Monthly rent
Acquisition Cost
Year Included
D
P
P
A
ECLARATION OF
ERSONAL
ROPERTY
FFIDAVIT
T
(
)
A
.
HIS FORM MUST BE SIGNED
AND IN SOME CASES WITNESSED
BEFORE IT MAY BE FILED WITH THE
SSESSOR
A
P
–
IMPROPERLY SIGNED DECLARATIONS REQUIRE A 25% PENALTY
VOID
ENALTY
C
S
A
S
B
OMPLETE
ECTION
OR
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 Town Assessor or postmarked (as defined in C.G.S.
Sec. 1-2a) by Monday, November 1, 2010 – a 25% Penalty required for failure to file as required.
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