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CLAIM FOR EXEMPTION OF                                                                   FORM 103-IT                                       JANUARY 1, _______ 
ENTERPRISE INFORMATION                                                                   PRIVACY NOTICE            For Assessor’s Use Only 
TECHNOLOGY EQUIPMENT                                                            This form contains confidential 
                                                                           information pursuant to IC 6-1.1-35-9. 
State Form 54182 (R5 / 1-23) 
Prescribed by the Department of Local Government Finance 
INSTRUCTIONS:  
1. In order to qualify for this exemption, entities must meet the requirements outlined in IC 6-1.1-10-44.
2. Qualifying equipment is defined in IC 6-1.1-10-44(c) and the definition does not include computer hardware designed for single user, workstation, or
department level use.
3. Entities should attach this form to the Form 103-Long and file it with the proper assessing official by May 15 or the extended due date.

SECTION 1                                                           TAXPAYER INFORMATION 
Name of Taxpayer 

Address of Taxpayer (number and street, city, state, and ZIP code) 

Name of Contact Person                                              Telephone Number                            Email Address 
                                                                    (         ) 
SECTION 2                               LOCATION AND DESCRIPTION OF PROPERTY 
Name of Designating Body                                                                                        Resolution Number 

Location of Property (number and street, city, state, and ZIP code) County                                      DLGF Taxing District Number 

Date of Acquisition            Tax Life General Description of Qualifying Equipment                                                        Cost 
(month, day, year) 
                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

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                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                                                                                                $ 

                                        TOTAL COST AS SHOWN ON LINE 6, SCHEDULE A, FORM 103                     $ 

Under the penalties of perjury, I hereby certify that this return, to the best of my knowledge and belief, is true, correct, complete, and reports the 
total cost of all personal property claimed by the taxpayer to be exempt from assessment and taxation pursuant to IC 6-1.1-10-44. 
Signature of Authorized Person                                             Title                                   Date (month, day, year) 

Signature of Person Preparing Return