Enlarge image
FORM 103 – SR JANUARY 1, 2024
SINGLE RETURN - PRIVACY NOTICE For Assessor's Use Only
BUSINESS TANGIBLE PERSONAL PROPERTY
State Form 53854 (R16 / 1-24) This form contains confidential
Prescribed by the Department of Local Government Finance information pursuant to IC 6-1.1-35-9.
NOTE: For taxpayers with less than $80,000 in acquisition costs to report within the county, legislation was passed in 2021 which exempts this property. If
you are declaring this exemption, please file Form 103 – Short or Form 103 – Long.
RETURN THIS FORM TO THE APPLICABLE ASSESSOR BY MAY 15, 2024.
SECTION I
Name of Taxpayer
Name for Assessment and Tax Notice to be Mailed County
Address for Assessment and Tax Notice to be Mailed (number and street, city, state, and ZIP code) Federal Identification Number **
Nature of Business NAICS Code Number *
SECTION II
1. Federal Income Tax Year Ends 2. Name Federal Return is Filed Under 3. Location of Accounting Records
4. Form of Business ☐ Partnership or Joint Venture ☐ Sole Proprietorship ☐ Corporation
☐ Estate or Trust ☐ Other (describe) ___________________________________________________
5. Did you own, hold, possess, or control any leased, rented, If yes, file Form 103 – N or Form 103 – O (see 50 IAC 4.2-8-3 and 4).
or other depreciable personal property on January 1? ☐ Yes ☐ No Failure to properly disclose lease information may result in a double assessment.
SECTION III
LOCATION SUMMARY: List each location where you own, hold, possess, or control personal property subject to Additional Locations
assessment. Include the complete address (street address) for each location. Assign a
location number to each separate location. Attach additional sheets if necessary. Page __________ of ___________
LOCATION TOWNSHIP DLGF TAXING NAME UNDER WHICH BUSINESS IS CONDUCTED (if different than above)
NUMBER DISTRICT NUMBER AND SPECIFIC STREET ADDRESS (number and street, city, state, and ZIP code)
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 – A complete list of codes may be found at: www.census.gov. For further information, contact that
assessor (contact information is available at: http://www.in.gov/dlgf/contact-your-local-officials).
** An individual using his/her Social Security Number as the Federal Identification Number is only required to provide the last four (4) digits of that number. IC 4-1-10-3
SECTION IV 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 Date (month, day, year)
Title of Authorized Person Telephone Number Email of Authorized Person
( )
Page ____ of ____
