State Form 11274 - Business Tangible Personal Property Return - 2016

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BUSINESS TANGIBLE

FORM 103 - SHORT

JANUARY 1, 2017

PERSONAL PROPERTY RETURN

For Assessor's Use Only

PRIVACY NOTICE

State Form 11274 (R35 / 11-16)

This form contains information

confidential pursuant to IC 6-1.1-35-9.

Prescribed by the Department of Local Government Finance

NOTE: For taxpayers with less than $20,000 cost to report within the county, legislation was passed in 2015 which exempts this property. If you are

declaring this exemption, check this box, enter the total acquisition cost of your personal property in the county, and complete only sections I and IV of this

form. If you are declaring this exemption through this form, you do not need to file a Form 104.

$ ________________________

RETURN THIS FORM TO THE APPLICABLE ASSESSOR BY MAY 15, 2017.

An exemption granted under IC 6-1.1-10 or any other statute supersedes this exemption. In other words, a taxpayer whose personal property is exempt

because the taxpayer applied for and was granted an exemption by the county must follow all applicable procedures for the approved exemption, which

may include fully completing the personal property return.

INSTRUCTIONS:

1. Please type or print.

2. This form must be filed with the Township Assessor, if any, or the County Assessor of the county in which the property is located not later than May 15, 2017,

unless an extension of up to thirty (30) days is granted in writing. Contact information for the Assessor is available at

3. A Form 104 must be filed with the return.

NOTE: You must use Form 103-Long if:

a. You are a manufacturer or processor;

b. Your business personal property assessment is $150,000 or more;

c. You wish to claim any exemptions or deductions (other than the enterprise zone credit); or

d. You are claiming any special adjustments such as equipment not placed in service, special tooling,

permanently retired equipment or abnormal obsolescence.

SECTION I

Name of taxpayer

Federal identification number **

Name under which business is conducted

DLGF taxing district number

Address where property is located (number and street, city, state, and ZIP code)

DLGF taxing district name

Nature of business

T ownship

Name and address to which Assessment and T ax Notice are to be mailed (If different than above)

County

NAICS Code number *

SECTION II

1. Federal income tax year ends

Retail merchant’s certificate number

2. Location of accounting records

3. Form of business

Partnership or Joint Venture

Sole Proprietorship

Corporation

Estate or Trust

Other (describe): ____________________________________________________________________________________________________

4. Do you have other locations in Indiana?

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

If yes, report it on Page 2 or file the Form 103-N or 103-O (See 50 IAC 4.2-8-3 & 4).

Yes

Note: Failure to properly disclose lease information may result in a double assessment.

SECTION III

SUMMARY (Round all numbers to nearest ten dollars)

REPORTED BY TAXPAYER

CHANGE BY ASSESSOR

CHANGE BY COUNTY BOARD

Schedule A - Personal Property

Final Assessed Value

SECTION IV

SIGNATURE AND VERIFICATION

Under penalties of perjury, I hereby certify that this return (including any accompanying schedules and statements), to the best of my knowledge and

belief, is true, correct, and complete; if applicable, 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, 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

Date (month, day, year)

Printed name of authorized person

T elephone number

Title

(

)

Signature of person preparing return, if different than authorized person

Contact e-mail address

Printed name and contact information of person preparing return

* NAICS - North American Industry Classification System - complete list of codes may be found at

NOTE: The NAICS Code Number appears on your federal income tax return.

** An individual using his Social Security number as the Federal Identification number is only required to provide the last four (4) digits of that number per IC 4-1-10-3.

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