Fillable Printable Form 53855
Fillable Printable Form 53855
Form 53855
Were expenditures made since the last assessment date for improvements on any real estate owned, possessed, or occupied by the taxpayer in the
township wherein this return is filed? Yes No
(If Yes, attach a statement setting forth: name of owner, location of real estate and explaining nature, cost, date construction or improvements were
begun 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]
SINGLE RETURN
BUSINESS TANGIBLE PERSONAL PROPERTY
State Form 53855 (R3 / 11-15)
Prescribed by the Department of Local Government Finance
JANUARY 1, 20___
For assessor's use only
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.
Name of taxpayer (please type or print)
Name under which business is conducted
Address where property is located (number and street, city, state, and ZIP code)
Nature of business
Name to which assessment and tax notice are to be mailed (if different than above)
Address to which assessment and tax notice are to be mailed (number and street, city, state, and ZIP code) (if different than above)
County
FILING 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.
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
NAICS code number*
* NAICS - North American Industry Classification System - complete list of codes may be found at www.census.gov. For further information, contact the
Assessor (contact information available on the DLGF website, www.in.gov/dlgf).
FORM 104-SR
SCHEDULE A - PERSONAL PROPERTY +
FINAL ASSESSED VALUE =
SUMMARY
(Round all numbers to nearest ten dollars)
LOCATION NUMBER
____________
$
$
LOCATION NUMBER
____________
LOCATION NUMBER
____________
Page ______ of ______
$
$
$
$
SCHEDULE A - PERSONAL PROPERTY +
FINAL ASSESSED VALUE =
SUMMARY
(Round all numbers to nearest ten dollars)
LOCATION NUMBER
____________
$
$
LOCATION NUMBER
____________
LOCATION NUMBER
____________
$
$
$
$
Reset Form
Summary of Assessed Values for all Locations in this County
(attach additional sheets, if necessary)
Additional sheets attached
Name of County
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 AND VERIFICATION
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 for a year, 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)]
TOWNSHIP
DLGF TAXING
DISTRICT NUMBER
NAME UNDER WHICH BUSINESS IS CONDUCTED (DBA) (if different than above)
AND SPECIFIC STREET ADDRESS (number and street, city, state, and ZIP code)
LOCATION
NUMBER
Name of taxpayer (please type or print)
Title
Signature of authorized person
Printed name of authorized person
Date (month, day, year)
Signature of person preparing return, if different than authorized person
Printed name of person preparing return, if different than authorized person
Page ______ of ______
