1. Healthcare

4.1.1 Business Personal Property First Declaration
2015 TAX YEAR
BUSINESS PERSONAL PROPERTY DECLARATION
JACKSON COUNTY, MISSOURI
DUE BY
MARCH 1, 2015
COUNTY ACCOUNT NUMBER
TCA
SIC/NAICS
CODE
001000001
000010011
011001
PROCESS
CODE
CLERK’S
INITIALS
ASSESSMENT DEPARTMENT
112 WEST LEXINGTON
INDEPENDENCE, MO 64050
(816) 881-4672
RECEIVED DATE
DATA
ENTERED
Please Make Name / Address Corrections Below
____________________________________________
LEGAL NAME OF CORPORATION (IF APPLICABLE)
____________________________________________
STATE OF INCORPORATION
TELEPHONE NUMBER
____________________________________________
NAME OF REGISTERED AGENT
______________________________________
____________________________________________
STATE OF MISSOURI – SALES TAX ID
MAILING ADDRESS OF REGISTERED AGENT
______________________________________
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
SITUS ADDRESS (PHYSICAL LOCATION OF PROPERTY)
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
ANY PERSON, CORPORATION, PARTNERSHIP OR ASSOCIATION, SUBJECT TO TAXATION UNDER THE LAWS OF MISSOURI, WHO OWNS OR
CONTROLS TANGIBLE PERSONAL PROPERTY ON JANUARY 1 OF EACH YEAR, IS REQUIRED BY LAW TO FILE (DECLARE) AN ITEMIZED LIST
OF ALL TANGIBLE PERSONAL PROPERTY WITH THE COUNTY ASSESSOR EACH YEAR BY MARCH 1. THE PERSON MAKING THE LIST
SHALL DO SO ON A PRINTED BLANK PREPARED FOR THAT PURPOSE (THIS COUNTY DECLARATION FORM). THE LIST (DECLARATION)
MUST BE SIGNED AND CERTIFIED BY THE TAXPAYER AS BEING A TRUE AND COMPLETE LIST OF ALL TAXABLE TANGIBLE PERSONAL
PROPERTY OWNED OR CONTROLLED AS OF JANUARY 1.
[RSMO 137.340 & 137.115 (4)]
ANY PERSON, CORPORATION, PARTNERSHIP OR ASSOCIATION WHO NEGLECTS OR REFUSES TO FILE AN ITEMIZED LIST WITH THE
COUNTY ASSESSOR BY MAY 1, SHALL BE ASSESSED A PENALTY BASED ON THE ASSESSED VALUE OF THE PROPERTY THAT WAS NOT
REPORTED.
[RSMO 137.345]
COMPLETE THE SECTION BELOW THAT APPLIES (Complete only ONE section)

I, DO HEREBY CERTIFY THAT THE LIST INCLUDED BELOW IN THIS DECLARATION CONTAINS A TRUE AND CORRECT STATEMENT
OF ALL THE TANGIBLE PERSONAL PROPERTY MADE TAXABLE BY THE LAWS OF THE STATE OF MISSOURI, WHICH I OWNED OR WHICH I
HAD UNDER MY CHARGE OR MANAGEMENT ON THE FIRST DAY OF JANUARY 2015. I FURTHER CERTIFY THAT I HAVE NOT SENT OR
TAKEN OR CAUSED TO BE SENT OR TAKEN, ANY PROPERTY OUT OF THIS STATE TO AVOID TAXATION. [RSMO 137.360]
______________________________________________________
TAXPAYER/CORPORATE OFFICER SIGNATURE
_________________________________
TITLE
______________________________________________________
PRINTED NAME
_________________________________
DATE
______________________________________________________
DECLARATION PREPARED BY (PREPARER’S NAME)
(____)______-______________
FAX
_______________________________________________________________
NAME OF FIRM

________@________
E-MAIL
(____)______-_______________
TELEPHONE NUMBER
I, DID NOT OWN OR CONTROL ANY TANGIBLE PERSONAL PROPERTY MADE TAXABLE BY THE LAWS OF THE STATE OF MISSOURI, ON THE FIRST DAY
OF JANUARY 2015.
THE BUSINESS WAS:
 CLOSED (DATE CLOSED _____________)
 SOLD (DATE SOLD ____________)
NAME & ADDRESS OF NEW OWNER (IF KNOWN): _______________________________________________________________________
THE FURNITURE, FIXTURES & EQUIP. WERE: (Check one)
 MOVED OUT OF JACKSON COUNTY, MO.
 LEFT AT THE BUSINESS LOCATION
 SOLD SEPARATELY
 MOVED TO A DIFFERENT LOCATION IN JACKSON COUNTY
LIST LOCATION: ________________________________________________________________________________
____________________________________________________
TAXPAYER/CORPORATE OFFICER SIGNATURE
__________________________________
TITLE
_____________@________
E-MAIL
____________________________________________________
PRINTED NAME
____________________________
DATE
__(____)______-___________________
TELEPHONE NUMBER
____________________________________________________
DECLARATION PREPARED BY (PREPARER’SNAME)
____________________________________________________________________
NAME OF FIRM
Page 1
4.1.1 Business Personal Property First Declaration
** ANSWER ALL OF THE FOLLOWING QUESTIONS **
Date business started in Jackson County, Missouri. ___________________
List the number of employees at this location.
___________________
Describe nature of business in Jackson County. ________________________________________________________
Check classification of business:
Retail
 Wholesale  Trades
 Profession
 Manufacturing
 Construction
 Service
 OTHER (explain): ________________
If this business has multiple locations, indicate the number in Jackson County and list their locations. # __________
Locations: ___________________________________________________________________________________________
Do you rent or lease personal property FROM others? (You are the lessee) __ Yes __ No
If yes, complete the “LEASED EQUIPMENT” section below.
Do you rent or lease personal property TO others?
(You are the lessor) __ Yes __ No
If yes, list that equipment on the appropriate schedule(s) on the following pages.
Are there any other individuals, partnerships, corporations, or joint ventures doing business on these premises? _ Yes __ No
If yes, please list: _____________________________________________________________________________________
If you are operating out of this location under more than one business name, please list names:
____________________________________________________________________________________________________
INSTRUCTIONS FOR FILING 2015 BUSINESS PERSONAL PROPERTY DECLARATION
Check the business name, mailing address, property location and telephone number for accuracy. Make corrections by drawing
a line through the incorrect information and writing in the correct information. DO NOT WHITE-OUT THE OLD NAME OR ACCOUNT
NUMBER. Please print clearly.
Complete ALL sections that apply to your business. Attach any additional information in the same format as the requested
information. Do not list personally owned (non-business use) vehicles or other property that you list on your individual personal property
declaration.
Complete the “I DO HEREBY CERTIFY” box on the front page if you owned taxable personal property on January 1, 2015.
Complete the “I DID NOT OWN” box if you did not own any taxable personal property on January 1, 2015. SIGN AND DATE
this form. Unsigned declarations will be returned for signatures and late filing penalties may be applied.
Return the declaration to the Jackson County Assessor’s Office by MARCH 1, 2015. Declarations received after the March 1
deadline, may have a late filing penalty applied to the assessed value of the property as required by state law.
Note: All tangible personal property used for business purposes must be listed for property tax purposes unless it is
expressly exempt by law, even if the item(s) has been fully depreciated for income tax or record keeping purposes.
The assessor may require a copy of the taxpayer’s depreciation schedule or other documentation to substantiate the
acquisition costs or value of the assets reported. You may include a copy of your depreciation schedule along with this
declaration.
Please note: RSMO 137.122 requires Business Personal Property placed in service after January 1, 2010 shall be
subject to specific rates of depreciation as listed below, with class life and recovery periods as followed by IRS
MACRS (Modified Accelerated Cost Recovery System) method of depreciation. This property can be listed net of any
sales tax, installation or freight.
A copy of your latest fixed asset ledger showing acquisition date and original cost of all assets should accompany this
declaration. All fixed assets as shown on your company’s financial records must be reported on this form, including items fully
depreciated and expensed.
COMPLETE ALL SCHEDULES THAT APPLY TO YOUR BUSINESS:
AUTOMOBILES: ( Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
SERIES
VEHICLE IDENTIFICATION NO.
Cylinders
TRUCKS (LT, MED, HEAVY DUTY), SUV’S, VANS, PICKUPS: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
SERIES/
TYPE
VEHICLE IDENTIFICATION NO.
BED TYPE
(flat, dump)
GVW /
Tonnage
No.
of
Apportioned
Axles
Yes
No
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4.1.1 Business Personal Property First Declaration
MOTORCYCLES, ATV’S, MOPEDS, SCOOTERS: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
TYPE OF
VEHICLE
VEHICLE IDENTIFICATION NO.
ENGINE
SIZE -CC’S
NO. OF WHEELS
HISTORIC LICENSED VEHICLES: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
SERIES
VEHICLE IDENTIFICATION NO.
Cylinders
BUSES: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
TYPE OF BUS
VEHICLE IDENTIFICATION NO.
LENGTH
NO. OF SEATS
RECREATIONAL VEHICLES, MOTOR HOMES: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
TYPE
(Trvl Trl, Mtr Hm,
5TH Wheel, etc.)
VEHICLE IDENTIFICATION NO.
LENGTH
SELF CONTD (Yes /
No)
WATERCRAFT, MOTORS & FLOATING BOAT DOCKS: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
BOAT TYPE: (Ski Boat,
Sailboat, Pontoon, etc)
MOTOR TYPE:
(Inboard, Outboard,
Stern)
MOTOR
HP
BOAT
LENGTH
STORED / LOCATED
AT
MARKET VALUE FLOATING BOAT DOCK $
TRAILERS: UTILITY, LIVESTOCK, SEMI, ETC (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL
TYPE OF TRL
VEHICLE IDENTIFICATION NO.
LENGTH /
CAPACITY
NO. OF AXLES
MOBILE/MANUFACTURED HOMES: (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL OR
SERIES
LENGTH
& WIDTH
VIN / SERIAL NUMBER
PROPERTY LOCATION IF DIFFERENT THAN
YOUR MAILING ADDRESS
LEASED EQUIPMENT: Copiers, postage meters, vending machines, etc. (Attach a list with the same format if additional space is needed.)
Name & Mailing Address of Leasing
Company
Description of Leased
Item(s)
Physical Location of
Item(s)
Is this a lease-purchase agreement?
(Y/N)
50 SUPPLIES: (Items that are replaced during the year) List dollar amount on hand as of January 1st $ ___________________________
AIRCRAFT: You must answer the questions below (Attach a list with the same format if additional space is needed.)
YEAR
MAKE
MODEL OR
SERIES
TYPE OF
AIRCRAFT
SERIAL NUMBER
N NUMBER
NO. OF ENGINES
COMPLETE THIS SECTION IF YOU ARE DECLARING AIRCRAFT
A.
Yes __ No __
Was your aircraft at least 25 years old as of January 1, 2015?
B.
Yes __ No __
Is your aircraft used solely for non-commercial purposes?
C.
Yes __ No __
Was your aircraft operated less than 50 hours during the last calendar year? Number of hours _________
D.
Yes __ No __
Is your aircraft homebuilt from a kit? If yes, please list the total cost to build your aircraft. $ _____________
E.
Yes __ No __
Was your aircraft flyable as of January 1, 2015?
F.
Yes __ No __
Is your aircraft maximum certified gross take-off weight 3,000 lb or more?
LIVESTOCK:
TYPE:
# OF
EACH
CATTLE/CALVES
HORSES/MULES/ASSES
HOGS/PIGS
SHEEP/GOATS
POULTRY
OTHER (Describe)
AGRICULTURAL CROPS:
TOTAL MARKET VALUE OF ALL GRAIN AND OTHER AGRICULTURAL CROPS IN UN-MANUFACTURED CONDITION $ ___________________
Page 3
4.1.1 Business Personal Property First Declaration
Please note: RSMO 137.122 requires Business Personal Property placed in service after
January 1, 2010 shall be subject to specific rates of depreciation as listed below, with class
life and recovery periods as followed by IRS MACRS (Modified Accelerated Cost Recovery
System) method of depreciation. This property can be listed net of any sales tax, installation
or freight.
OFFICE FURNITURE AND EQUIPMENT, FIXTURES, MACHINERY and CONSTRUCTION
EQUIPMENT: (Include signs, underground tanks) RADIO & TV BROADCAST EQUIPMENT &
OTHER
ACQUISITION COST
YEAR OF ACQUISITION
AT 100% PURCHASE
% GOOD FACTOR ASSESSED VALUE
PRICE
2013
7yr Life
89% x 33.3%
2012
7yr Life
70% x 33.3%
2011
7yr Life
55% x 33.3%
2010
7yr Life
43% x 33.3%
60 MANUFACTURING EQUIPMENT: (Machinery & equipment NOT controlled by computers)
ACQUISITION COST AT
% GOOD
ASSESSED
YEAR OF ACQUISITION
100% PURCHASE PRICE
FACTOR
VALUE
2009
2008
43% x 33.3%
40% x 33.3%
30% x 33.3%
ALL PRIOR YRS
TOTALS
70 COMPUTERIZED MANUFACTURING EQUIPMENT: (Computer controlled machinery &
equipment)
ACQUISITION COST AT 100%
% GOOD
ASSESSED
YEAR OF ACQUISITION
PURCHASE PRICE
FACTOR
VALUE
2009
2008
42% x 33.3%
33% x 33.3%
15% x 33.3%
ALL PRIOR YRS
COMPUTER & TELECOMMUNICATIONS EQUIPMENT: (Telephone systems, computers,
peripheral equipment, etc,) & TYPEWRITERS, CALCULATORS, COPIERS AND DUPLICATING
EQUIPMENT
ACQUISITION COST
YEAR OF ACQUISITION
AT 100% PURCHASE % GOOD FACTOR ASSESSED VALUE
PRICE
2013
5yr Life
85% x 33.3%
2012
5yr Life
59% x 33.3%
2011
5yr Life
41% x 33.3%
2010
5yr Life
25% x 33.3%
MOVIE RENTAL TAPES & VIDEO GAME MACHINES: (you rent to others) & SPECIALTY
DIES AND MOLDS
2013
3yr Life
2012
3yr Life
2011
3yr Life
2010 and prior years
3yr Life
75% x 33.3%
37% x 33.3%
12% x 33.3%
TOTALS
10 FURNITURE, FIXTURES, MACHINERY & EQUIPMENT and CONSTRUCTION EQUIPMENT:
(Include tools, signs, underground tanks)
ACQUISITION COST AT 100% % GOOD
ASSESSED
YEAR OF ACQUISITION
PURCHASE PRICE
FACTOR
VALUE
2009
2008
43% x 33.3%
40% x 33.3%
30% x 33.3%
ALL PRIOR YRS
TOTALS
20 COMPUTER & TELECOMMUNICATIONS EQUIPMENT: (Telephone systems, computers,
data processing equipment, ect.)
ACQUISITION COST AT 100% % GOOD
ASSESSED
YEAR OF ACQUISITION
PURCHASE PRICE
FACTOR
VALUE
2009
2008
5% x 33.3%
Other MACRS life Equipment tables for 10, 15, 20 year life property
20% x 33.3%
10% x 33.3%
5% x 33.3%
ALL PRIOR YEARS
TOTALS
YEAR OF ACQUISITION
ACQUISITION
COST AT 100%
PURCHASE PRICE
% GOOD
FACTOR
2013
2012
2011
2010
2013
2012
2011
2010
10yr Life
10yr Life
10yr Life
10yr Life
15yr Life
15yr Life
15yr Life
15yr Life
92% x 33.3%
78% x 33.3%
66% x 33.3%
57% x 33.3%
95% x 33.3%
85% x 33.3%
77% x 33.3%
69% x 33.3%
2013
20yr Life
96% x 33.3%
2012
20yr Life
89% x 33.3%
2011
20yr Life
82% x 33.3%
2010
20yr Life
76% x 33.3%
ASSESSED VALUE
A copy of your latest fixed asset ledger showing acquisition date and original cost of all
assets should accompany this declaration. All fixed assets as shown on your company’s
financial records must be reported on this form, including items fully depreciated and
expensed. If you are unsure what recovery period applies to your property please consult
your tax professional or the IRS MACRS tables, which can be found at www.IRS.GOV.
Page 4