Personal Property Declaration - Long form 2023GL
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2023 Connecticut
Declaration of Personal Property
Filing Requirement – This declaration must be filed with the Assessor of the town where the personal property is located. Declarations of
personal property shall be made annually.
If you no longer own the above noted business or personal property assessed in your name last year, you do not need to complete this
declaration. You must, however, return this declaration to the Assessor and provide information related to the name of the new owner of the
property or the date your business ceased or to where you moved the business (see Affidavit below). Otherwise, the Assessor must assume
that you still own and are operating the business and have failed to declare your taxable personal property.
AFFIDAVIT OF BUSINESS TERMINATION OR MOVE OR SALE OF BUSINESS OR PROPERTY
I
of
at
Business or property owners name
Business Name (if applicable)
Street location
With regards to said business or property I do so certify that on
Said business or property was (Please appropriate box):
Date
SOLD TO:
Name
Address
MOVED TO:
City/Town and State to where business or property was moved
Address
TERMINATED:
Attach Bill of Sale or Letter of Dissolution to this form and return it with this affidavit to the Assessor’s office
The signer is made aware that the penalty for making a false affidavit is a $500.00 fine or imprisonment for one year or both.
Signature
Print name
Penalty for late filing – Failure to file timely will result in a penalty equal to 25% of the assessment of the personal property. This
declaration must be filed or postmarked (as defined in C.G.S. Sec 1-2a & as referenced in Sec. 12-41(d)) no later than:
Wednesday, November 1, 2023
I N S T R U C T I O N S
As per CGS 12-63, the Assessor must determine the “present true and actual value” and in determining such value may use the accepted
methods of comparable sales, cost less depreciation and income capitalization.
Not all sections are applicable to every business. Please read the following instructions and complete all relevant sections.
Who Should File --
All owners of taxable personal property.
Declaration –
1. Owners of:
a. Non-Connecticut registered motor vehicles
b. Horses, ponies and thoroughbreds
c. Mobile manufactured home -not assessed as real estate
2. Businesses, occupations, farmers, and professionals
need to complete: (Commercial and cost information is not
open to public inspection )
Business Data (page 3).
Lessee’s Listing Report (page 4).
Disposal, Sale or Transfer of Property Report (page 4).
Taxable Property Information (pages 5-7).
Sign the Declaration of Personal Property Affidavit on
page 8.
3. Lessors need to complete: (Commercial and cost information
is not open to public inspection )
Business Data (page 3).
Lessor’s Listing Report (page 3).
Disposal, Sale or Transfer of Property Report (page 4).
Taxable Property Information (pages 5-7).
Sign the Declaration of Personal Property Affidavit on
page 8.
Filing Requirements –
1. The Personal Property Declaration must be filed annually on
or before November 1 (or the Monday following if November 1
falls on Saturday or Sunday) (CGS §12-42).
2. A Personal Property Declaration not filed will result in a value
determined by the Assessor from the best available
information (CGS §12-53b).
3. Declarations filed with “same as last year” are INSUFFICIENT
and shall be considered an incomplete declaration.
4. Pursuant to CGS 12-81(79) tangible personal property older
than 10 years and with an original value of not more than
$250 is exempt. This exemption shall not be applied for the
first ten full assessment years following the assessment year
in which the property was acquired. Complete “Detailed
Listing of Assets Orig Value ≤ $250” report on Page 4. Also
list total value of such exempt assets in “Reconciliation of
Fixed Assets” box on Page 6.
Penalty of 25% is applied –
1. When no declaration is filed or a declaration is not signed, a
25% penalty is applied to the assessment. [See 2. under
Filing Requirements.]
2. When declarations are submitted after November 1 [See 1.
under Filing Requirements] and an extension has NOT been
granted (see Extensions) a 25% penalty is applied to the
assessment. Returns mailed in must have a postmark (as
defined in C.G.S. Sec 1-2a) of November 1 [See 1. under
Filing Requirements.] or before.
3. When an extension is granted (see Extensions) and the
declaration is not filed by the extension deadline, a 25%
penalty is applied to the assessment.
4. When omitted property is discovered, the 25% penalty is
applied to the difference in the assessed value as determined
by the results of the discovery and the assessment as
determined by the originally filed declaration.
Exemptions-
1. On page 7, check the box adjacent to the exemption you are
claiming.
2. Note that several exemptions require an additional application
in order to receive that exemption. Please request the form
number noted from the Assessor’s Office. The Manufacturers
Machinery & Equipment Exemption Claim form & its itemized
lists for Code 13 property may be requested if not included
with this declaration.
3. The extension to file the Personal Property Declaration, if
granted, may not apply to all required exemption applications
and may require a late filing fee. Check with the Assessor.
Signature Required –
1. The owners shall sign the declaration (page 8).
2. The owner’s agent may sign the declaration. In which case
the declaration must be duly sworn to or notarized.
3. Corporate officers signing for their corporations must have the
returns properly sworn to or notarized; or provide the
Assessor with a statement bearing the corporate seal and
signed by the corporate secretary setting out the office held by
the signer of the declaration and dates office held.
Extension –
The Assessor may grant a filing extension for good cause
(CGS §12-42 &12-81K). If a request for an extension is
needed, you need to request the filing extension in writing
on or before November 1, 2023 (PA 19-210).
Audit –
The Assessor is authorized to audit declarations, within 3
years of the date of the required filing. Substantial penalties
are applicable if such an audit reveals property not declared
as required by law (CGS §12-53).
Before Filing
Make Copies of Completed Declaration
for Your Records
Example of how to complete the tables on pages 5 and 6
#16 - Furniture, fixtures and equipment
Assessor’s
Use Only
How should the following be declared?
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
June 2022, you bought a desk for $800 and a chair
for $200. You have a filing cabinet and printer that
you bought 10 years ago for $2000 that is being
used in your business.
See the table to the right for the answer.
10-1-23
95%
10-1-22
1000
90%
900
10-1-21
80%
10-1-20
70%
10-1-19
60%
10-1-18
50%
10-1-17
40%
Prior Yrs
2000
30%
600
Total
3000
Total
1500
#16
1500
Page 2
2023 PERSONAL PROPERTY DECLARATION
Commercial and financial information is not open to public inspection
List or Account #:
Assessment date October 1, 2023
Owner’s Name:
Required return date November 1, 2023
DBA:
Location (street & number)
BUSINESS DATA For businesses, occupations, professions, farmers, lessors Answer all questions 1 through 12, writing N/A on lines that are not applicable.
1. Direct questions concerning return to -
2. Location of accounting records -
Name
Address
City/State/Zip
Phone / Fax
( )
/ ( )
( )
/ ( )
E-mail
3. Description of Business
4. How many employees work in your facilities in this town only?
5. Date your business began in this town?
6. How many square feet does your firm occupy at your location(s) in this town?
Sq. ft.
Own Lease
7. Type of ownership:
Corporation Partnership LLC Sole proprietor Other-Describe
8. Type of business:
Manufacturer Wholesale Service Profession Retail/Mercantile Tradesman Lessor
Other-Describe
IRS Business Activity Code
Yes
No
9. In the last 12 months was any of the property included in this declaration located in another Connecticut town
for at least 3 months? If yes, identify by specific months, code, cost, and location(s).
.
.
10. Are there any other business operations that are operating from your address here in this town?
If yes, give name and mailing address.
.
.
11. Do you own tangible personal property that is leased or consigned to others in this town?
If yes, complete Lessor’s Listing Report (below)
.
.
12. Did you have in your possession on October 1st any borrowed, consigned, stored or rented property?
If yes, complete Lessee’s Listing Report (page 4)
.
.
LESSOR’S LISTING REPORT In order to avoid duplication of assessments related to leased personal property, the following must be completed by
Lessors: (Please note that property under conditional sales agreements must be reported by the lessor.) Computerized filings are acceptable as long as all
information is reported in prescribed format.
Lessee #1
Lessee #2
Lessee #3
Name of Lessee
Lessee’s address
Physical location of equipment
Full equipment description
Is equipment self-manufactured?
Yes No
Yes No
Yes No
Acquisition date
Current commercial list price new
Has this lease ever been purchased,
assumed or assigned?
Yes No
Yes No
Yes No
If yes, specify from whom
Date of such purchase, etc.
If original asset cost was changed by
this transaction, give details.
Type of lease
Operating Capital Conditional Sale
Operating Capital Conditional Sale
Operating Capital Conditional Sale
Lease Term – Begin and end dates
Monthly contract rent
Monthly maintenance costs if included
in monthly payment above
Is equipment declared on the Lessor’s
or the Lessee’s manufacturing
exemption application?
Yes
No
Lessor
Lessee
Yes
No
Lessor
Lessee
Yes
No
Lessor
Lessee
Page 3
List or Account#:
Assessment date October 1, 2023
Owner’s Name:
Required return date November 1, 2023
LESSEE’S LISTING REPORT 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.
Yes
No
Did you dispose of any leased items that were in your possession on October 1, 2022? 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, 2022?
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
Phone Number
Lease Number
Item description /
Model #
Serial #
Year of manufacture
Capital Lease
Yes No
Yes No
Yes No
Lease Term –
Beginning/End
Monthly rent
Acquisition Cost
Year Included
DISPOSAL, SALE OR TRANSFER OF PROPERTY REPORT
Disposal, sale or transfer of property – If you disposed of, sold or transferred a portion of the property included in last year’s filing, complete the Detailed Listing
Of Disposed Assets Report And Reconciliation Of Fixed Assets on page 6. If you no longer own the business noted on the cover sheet you do not need to
complete this declaration. You must, however, return to the Assessor this declaration along with the complete AFFIDAVIT OF BUSINESS CLOSING OR MOVE OF
BUSINESS OR SALE OF BUSINESS FOUND in this return. DO NOT INCLUDE DISPOSALS IN TAXABLE PROPERTY REPORTING SECTION.
DETAILED LISTING OF DISPOSED ASSETS COPY AND ATTACH ADDITIONAL SHEETS IF NEEDED
Date Removed
Code #
Description of Item
Date Acquired
Acquisition Cost
DETAILED LISTING OF ASSETS ORIG VALUE ≤ $250 COPY AND ATTACH ADDITIONAL SHEETS IF NEEDED
Pursuant to CGS 12-81(79) – Listing of assets purchased prior to 10/1/13 with an original value ≤ $250
Description of Item
Date Acquired
Acquisition Cost
TAXABLE PROPERTY INFORMATION
1)
All data reported should be:
a)
Actual acquisition costs including any additional charges for
transportation and installation by year for each type of property
described. These costs, less the standard depreciation as shown
on the form will determine the net depreciated value.
b)
Include all assets that may have been fully depreciated, written
off, or charged to expense but are still owned. Do not include
disposed assets.
2)
Reports are to be filed on an assessment year basis of October 1.
Acquisitions between October 2 and December 31 apply to the new
year. (i.e. acquisition made October 30, 2022 is reported in the year
ending October 1, 2023).
3)
Computerized filings are acceptable as long as all information is
reported in prescribed format.
4)
Do not include disposed assets. Disposals are used to reconcile last
year’s reporting with this year’s reporting.
Page 4
List or Account#:
Assessment date October 1, 2023
Owner’s Name:
Required return date November 1, 2023
# 9 – Motor Vehicles Unregistered motor vehicles & vehicles
garaged in Connecticut but registered in another state
#10 – Manufacturing machinery & equipment not eligible under
CGS 12-81 (76) (MM&E) for exemption and any for assets
included on DECD EZ M47 form.
Assessor’s
Use Only
VEHICLE 1
VEHICLE 2
VEHICLE 3
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
Year
Make
10-1-23
95%
Model
10-1-22
90%
VIN
10-1-21
80%
Length
10-1-20
70%
Weight
10-1-19
60%
Purchase $
10-1-18
50%
Date
10-1-17
40%
Prior Yrs
30%
# 9
Value
Total
Total
#10
#11 – Horses and Ponies
#12 – Commercial Fishing Apparatus
#1
#2
#3
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
Breed
Registered
10-1-23
95%
Age
10-1-22
90%
Sex
10-1-21
80%
Quality
10-1-20
70%
Breeding
10-1-19
60%
Show
10-1-18
50%
Pleasure
10-1-17
40%
Racing
Prior Yrs
30%
#11
Value
Total
Total
#12
#13 – Manufacturing machinery & equipment eligible under
CGS 12-81(76) for exemption - must complete exempt claim.
#14 – Mobile Manufactured Homes if not currently assessed
as real estate
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
#1
#2
#3
Year
10-1-23
95%
Make
10-1-22
90%
Model
10-1-21
80%
ID Number
10-1-20
70%
Length
10-1-19
60%
Width
10-1-18
50%
Bedrooms
10-1-17
40%
Baths
Prior Yrs
30%
#13
Total
Total
Value
#14
#16 - Furniture, fixtures and equipment
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
10-1-23
95%
10-1-22
90%
10-1-21
80%
10-1-20
70%
10-1-19
60%
10-1-18
50%
10-1-17
40%
Prior Yrs
30%
Total
Total
#16
#17 – Farm Machinery
#18 – Farm Tools
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
10-1-23
95%
10-1-23
95%
10-1-22
90%
10-1-22
90%
10-1-21
80%
10-1-21
80%
10-1-20
70%
10-1-20
70%
10-1-19
60%
10-1-19
60%
10-1-18
50%
10-1-18
50%
10-1-17
40%
10-1-17
40%
Prior Yrs
30%
Prior Yrs
30%
#17
Total
Total
Total
Total
#18
Page 5
List or Account#:
Assessment date October 1, 2023
Owner’s Name:
Required return date November 1, 2023
#19 – Mechanics Tools
# 20 -- Electronic data processing equipment
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
In accordance with Section 168 IRS Codes
Computers Only
10-1-23
95%
10-1-22
90%
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
10-1-21
80%
10-1-20
70%
10-1-23
95%
10-1-19
60%
10-1-22
80%
10-1-18
50%
10-1-21
60%
10-1-17
40%
10-1-20
40%
Prior Yrs
30%
Prior Yrs
20%
#19
Total
Total
Total
Total
#20
#21a Telecommunication company equipment not techno-
logically advanced –include previously coded #21c property
with #21a
#21b Telecommunication company equipment technologically
advanced–include previously coded #21d property with #21b
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
10-1-23
95%
10-1-23
95%
10-1-22
90%
10-1-22
80%
10-1-21
80%
10-1-21
60%
10-1-20
70%
10-1-20
40%
10-1-19
60%
Prior Yrs
20%
10-1-18
50%
Total
Total
10-1-17
40%
Prior Yrs
30%
Total
Total
21a and 21b Total
#21
#22 – Cables, conduits, pipes, Class I Renewables, etc.
# 23 - Expensed Supplies
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
The average is the total amount expended on supplies since
October 1, 2022 divided by the number of months in business
since October 1, 2022.
10-1-23
10-1-22
Year
Ending
Total Expended
# of
Months
Average Monthly
10-1-21
10-1-20
10-1-23
10-1-19
10-1-18
10-1-17
Prior Yrs
Total
Total
#22
Check here if a FERC or PURA regulated utility
#23
#24a – Other Goods - including leasehold improvements
#24b -- Rental Entertainment Medium
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
Year
Ending
Original cost, installation
& transportation
%
Good
Depreciated Value
10-1-23
95%
10-1-23
95%
10-1-22
90%
10-1-22
80%
10-1-21
80%
10-1-21
60%
10-1-20
70%
10-1-20
40%
10-1-19
60%
Prior Yrs
20%
10-1-18
50%
Total
Total
10-1-17
40%
# of video tapes
# of DVD movies
Prior Yrs
30%
# of music CD’s
# of video games
Total
Total
24a and 24b Total
#24
RECONCILIATION OF FIXED ASSETS
Assets declared last October 1, 2022
Assets disposed of since last October 1, 2022*
-
Assets added since last October 1, 2022
+
Assets originally valued ≤ $250 & over 10 years old **
-
Assets declared this year October 1, 2023
Amount of expensed equipment last year
Capitalization Threshold
*Complete Detailed Listing of Disposed Assets –page 4
Page 6
** Assets Orig Value ≤ $250 – page 4
2023 PERSONAL PROPERTY DECLARATION – SUMMARY SHEET
Commercial and financial information is not open to public inspection.
List or Account#:
Assessment date October 1, 2023
Required return date November 1, 2023
Owner’s Name:
This Personal Property Declaration must be signed
and delivered or postmarked by
Wednesday, November 1, 2023 to
Assessor of Town
where property is located
DBA:
Mailing address:
City/State/Zip:
Location (street & number)
ASSESSOR’S
USE ONLY
Property Code and Description
Net Depreciated
Value pages 5 & 6 Code ASSESSMENTS
#9 Motor Vehicles UNREGISTERED motor vehicles (e.g. campers, RV’s, snowmobiles, trailers, trucks, passenger cars,
tractors, off-road construction vehicles, etc.) including any vehicle garaged in Connecticut but registered in another state, or any
such vehicle not registered at all. If you are a farmer eligible for the exemption under Sec. 12-91, list tractors in Code 17.
#9
#10 - Machinery & Equipment Industrial manufacturing machinery and equipment (e.g., tools, dies, jigs, patterns, etc.).
Include air and water pollution control equipment.
#10
#11 Horses And Ponies Describe your horses and ponies. A $1,000 assessment exemption per animal will be applied. If you
are a farmer, the exemption may be 100% provided Form M-28 is filed with and approved by the Assessor.
#11
#12 - Commercial Fishing Apparatus All fishing apparatus exclusively used by a commercial fisherman in his business
(e.g., fishing poles, nets, lobster pots, fish finders, etc.). A $500 value exemption will be applied.
#12
#13 –Manufacturing machinery & equipment Manufacturing machinery and equipment used in manufacturing; used in
research or engineering devoted to manufacturing; or used for the significant servicing or overhauling of industrial machinery or
factory products and eligible for exemption under CGS 12-81 (76). (Formerly property Codes 13 & 15)
#13
#14 Mobile Manufactured Homes if not currently assessed as real estate
#14
#16 - Furniture & Fixtures Furniture, fixtures and equipment of all commercial, industrial, manufacturing, mercantile, trading
and all other businesses, occupations and professions. Examples: desks, chairs, tables, file cabinets, typewriters, calculators,
copy machines, telephones (including mobile telephones), telephone answering machines, facsimile machines, postage meters,
cash registers, moveable air conditioners, partitions, shelving display racks, refrigerators, freezers, kitchen equipment, etc.
#16
#17 - Farm Machinery Farm machinery (e.g., tractors, harrows, bush hogs, hay bines, hay rakes, balers, corn choppers,
milking machines, milk tanks, coolers, chuck wagons, dozers, back hoes, hydroponic farm equipment, aquaculture equipment,
etc.), used in the operation of a farm.
#17
#18 - Farming Tools Farm tools (e.g., hoes, rakes, pitch forks, shovels, hoses, brooms, etc.).
#18
#19 - Mechanics Tools Mechanics tools (e.g., wrenches, air hammers, jacks, sockets, etc.).
#19
#20 - Electronic Data Processing Equipment Electronic data processing equipment (e.g., computers, printers, peripheral
computer equipment, and any computer based equipment acting as a computer as defined under Section 168 of the IRS Code of
1986, etc.). Bundled software is taxable and must be included.
#20
#21 - Telecommunications Equipment Excluding furniture, fixtures, and computers, #21a includes cables, conduits,
antennae, batteries, generators or any equipment not deemed technologically advanced by the Assessor. #21b includes
controllers, control frames, relays switching and processing equipment or other equipment deemed technologically advanced by
the Assessor.
#21
#22 - Cables, conduits, pipes, poles, towers (if not currently assessed as real estate), underground mains, wires,
turbines, Class I Renewables, Cylinder and other Tanks of gas, heating, or energy producing companies, telephone
companies, water and water power companies. Include items annexed to the ground (e.g., hydraulic car lifts, gasoline holding
tanks, pumps, truck scales, etc.), as well as property used for the purpose of creating or furnishing a supply of water (e.g. pumping
stations).
#22
#23 - Expensed Supplies The average monthly quantity of supplies normally consumed in the course of business (e.g.,
stationery, post-it notes, toner, computer disks, computer paper, pens, pencils, rulers, staplers, paper clips, medical and dental
supplies and maintenance supplies, etc.).
#23
#24 – Other All Other Goods, Chattels and Effects Any other taxable personal property not previously mentioned or which
does not appear to fit into any of the other categories. (e.g., video tapes, vending machines, pinball games, video games, signs,
billboards, coffee makers, water coolers, leasehold improvements and construction in progress (CIP).
#24
Total Net Depreciated and Assessment – all codes #9 through #24
Subtotal >
#25 – Penalty for failure to file as required by statute – 25% of assessment
#25
Exemption - Check box adjacent to the exemption you are claiming:
I – Farming Tools - $500 value I – Horses/ponies $1000 assessment per animal I – Mechanic’s Tools - $500 value
K – Municipal Leased M – Commercial Fishing Apparatus - $500 value
All of the following exemptions require a separate application and/or certificate to be filed with the Assessor by the required return date
G & H – Distressed Municipality/Enterprise Zone/Enterprise Corridor Zone - Exemption application M-55 required annually
I – Farm Machinery $100,000 assessment - Exemption application M-28 required annually
J – Class I Renewable - Exemption Application M-44 required.
J – Water Pollution or Air Pollution control equipment – Connecticut DEEP certificate required – provide copy
U – Manufacturing Machinery & Equipment Claim Form - Exemption claim required annually
Assessor’s Final Assessment Total >
Page 7
List or Account#:
Assessment date October 1, 2023
Owner’s Name:
Required return date November 1, 2023
Notes:
This Personal Property Declaration must be signed above and delivered to the Assessor or postmarked
(as defined in C.G.S. Sec 1-2a & as referenced in Sec. 12-41(d)) by Wednesday, November 1, 2023
to avoid the 25% Penalty required for failure to file.
Page 8
DECLARATION OF PERSONAL PROPERTY AFFIDAVIT
THIS FORM MUST BE SIGNED (AND IN SOME CASES WITNESSED) BEFORE IT MAY BE FILED WITH THE ASSESSOR.
AVOID PENALTY – IMPROPERLY SIGNED DECLARATIONS REQUIRE A 25% PENALTY
COMPLETE SECTION A OR SECTION B
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 §12-49 C.G.S.
SEE PAGE TWO (2) FOR SIGNATURE REQUIREMENTS.
CHECK ONE
OWNER
PARTNER
CORPORATE OFFICER
MEMBER
Signature
Dated
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
Check Off List:
Direct questions concerning declaration to the Assessor’s Office
Read instructions on page 2
where property is located.
Complete appropriate sections
Complete exemption applications
Sign & date as required on page 8
Make a copy for your records
Return by November 1, 2023