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         SINGLE RETURN BUSINESS TANGIBLE                                                                                                   JANUARY 1, _______ 
         PERSONAL PROPERTY                                                                            FORM  104-SR                       For Assessor's Use Only 
         State Form53855 (R6 / 1-23) 
         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.
NOTE: For taxpayers with less than $80,000 in acquisition costs to report within the county, legislation was passed in 2021 which exempts the property. If you 
are declaring this exemption, please file Form 103-Short or Form 103-Long.  

                                                                  TAXPAYER INFORMATION 
Name of Taxpayer (please type or print)                                                                                   County 

Name Business is Conducted Under                                                                                          NAICS Code Number* 

Property Address (number and street, city, state, and ZIP code) 

Nature of Business 

Name for Assessment and Tax Notice (if different than above) 

Mailing Address for Assessment and Tax Notice (number and street, city, state, and ZIP code) (if different than above) 

                                                                    FILING REQUIREMENT 
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,                              Yes      ☐    No
or occupied by the taxpayer in the township wherein this return is filed?                                                           ☐
(If Yes, attach a statement setting forth: name of owner, location of real estate and explaining nature, cost, beginning date of construction or improvements, 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 – A complete list of codes may be found at: www.census.gov. For further information, contact the
assessor (contact information is available at: http://www.in.gov/dlgf/contact-your-local-officials).

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Name of Taxpayer (please type or print) 

                                                                                                               Name of County 
Summary of Assessed Values for all Location in this County      ☐           Additional Sheets Attached
(attach additional sheets, if necessary) 

LOCATION                   TOWNSHIP           DLGF TAXING       NAME UNDER WHICH BUSINESS IS CONDUCTED (DBA) (if different than above) 
NUMBER                                        DISTRICT NUMBER               AND SPECIFIC STREET ADDRESS (number and street, city, state, and ZIP code) 

                                         PENALTIES FOR FAILURE TO FILE COMPLETE RETURN FORMS 
Failure to file a return on or before the due date, as required by law, will result in the imposition of a twenty-five dollar ($25.00) penalty. In addition, if a 
return is not filed within thirty (30) days after such return is due, a penalty equal to twenty percent (20%) of the taxes finally determined to be due with 
respect to the property which should have been reported will be imposed. A personal property return is not due until the expiration of any extension period 
granted by the township assessor or county assessor under IC 6-1.1-3-7(b). 
If the total assessed value that a person reports on a personal property return is less than the total assessed value that the person is required by law to 
report and if the amount of the undervaluation exceeds five percent (5%) of the value that should have been reported on the return, then the county 
auditor shall add a penalty of twenty percent (20%) of the additional taxes finally determined to be due as a result of the undervaluation. 
In completing a personal property return, a taxpayer must make a complete disclosure of all information relating to the value, nature, or location of 
personal property owned, held, possessed, or controlled on the assessment date [IC 6-1.1-3-9(a)], and information relating to improvements made since 
the preceding assessment date to real property owned, possessed, or occupied by the taxpayer [IC 6-1.1-5-13]. This information would include, but not be 
limited to, completion of the heading and related information, answers to all questions and entries on all of the appropriate lines on the face of the return. If 
such information is not provided, the taxpayer will be contacted and directed to provide that information. In addition, a penalty of twenty-five dollars 
($25.00) will be imposed.  [IC 6-1.1-37-7(d)] 
The above penalties are due on the property tax installment next due for the return whether or not an appeal is filed with the Indiana Tax Court with 
respect to the tax due on that installment.  [IC 6-1.1-37-7(f)] 

                                              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, complete, and 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 
                                                                (         ) 

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