PERSONAL PROPERTY…

                                                 PERSONAL PROPERTY REPORT
                                                Cowlitz County Assessor - Business Division
                                                       Personal Property Department
                                                       207 4th Avenue N., Room 203B
                                                              Kelso, WA 98626
                                                        360.577.3010 EXTENSION 02610

Please file by March 31. DUE DATE IS APRIL 30.
Penalty for filing after April 30th up to 25% (See RCW 84.40.130).
PARCEL #:                                    ASSESSMENT YEAR:                         TAX YEAR:                      TAX CODE:




LISTING OF PERSONAL PROPERTY:
RCW 84.40 and WAC 458.12 - Every person, firm, corporation, partnership or association, regardless of residency, who owns/controls
assessable/taxable personal property in this state as of 12:00 noon, January 1, is required to annually submit a complete list.


PROPERTY LOCATION:


HEAD OF FAMILY EXEMPTION (If sole owner of listed property):


Are you a citizen over 65 years old with 10 years continuous state residence?                                  YES                   NO
Are you the head of a family?                                                                                  YES                   NO
Do you claim Head of Family in any other county?                                                               YES                   NO
Are you a widow or widower?                                                                                    YES                   NO


IF A CORPORATION, PARTNERSHIP, LLC OR ASSOCIATION:
Corporation name:
Owner name/Officer name/ Title:


                                                                                                            Date:
NAME OF AUTHORIZED PERSON SUBMITTING REPORT

                                                                                                        Phone #:
ADDRESS / PO BOX

                                                                                                 Email Address:
CITY                        STATE                        ZIP



SUPPLIES:
$
Please see the Instructions for Filing Personal Property Report.


LEASED FURNITURE / FIXTURES / MACHINERY AND EQUIPMENT OWNED BY OTHERS:
         OWNER & ADDRESS                         EQUIPMENT DESCRIPTION                    LEASE PURCHASE               DATE       TERM     COST
                                                 SERIAL NUMBER / MODEL                     YES            NO




EQUIPMENT FORMERLY LEASED NOW OWNED BY TAXPAYER:
                LESSOR                            EQUIPMENT / TYPE / SERIAL NUMBER                          LEASE DATE            ORIGINAL COST*
                                                                                                        BEGIN           END




*Include all costs, transportation, engineering, and installation.
LEASEHOLD IMPROVEMENTS:
                 LEASEHOLD IMPROVEMENT DESCRIPTION                                   LESSEE COST             YEAR      REVERSION
                                                                                                          INSTALLED   YES      NO




ITEMIZED LISTING OF FURNITURE, FIXTURES, MACHINERY AND EQUIPMENT:
Please attach a copy of your most current asset listing used for IRS depreciation schedule.
        ASSET #                         ASSET DESCRIPTION, MAKE, MODEL                            YEAR PLACED         TOTAL COST**
                                (PLEASE INCLUDE SERIAL NUMBER IF AVAILABLE)                        IN SERVICE




**The cost should include all installation, engineering and shipping charges. Please do not include sales tax.
 If additional space is needed, please attach a separate sheet.