Agenda - 11-21-16 Reg. Meeting - Laserfiche WebLink

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I 424 SCIHEDULErD SEPARATELY SCHEDULED PROPERTY 1. Does your business own any artwork, displays, statues, or other personal property that is separately scheduled for insurance purposes? C YES 4 NO Please describe the items and estimated value of items if applicable. $C#EDILEE'" FARM EQUIPMENT Does your business own any tractors and/or other farm equipment? , -, YES 4 NO Cost on Schedule A If so, list and attach separate schedule E-1. If listed by cost on Schedule A, indicate above but still include information on separate schedule. E-1. SC -tWil F-' INTANGIBLE PERSONAL PROPERTY Do you lease or rent real property from exempt owners, such as a church, local, state, or federal government, an airport authority, university, or other exempt owner? f YES 4 NO If yes, include lease information below. Attach additional schedule if necessary. NAME AND ADDRESS OF OWNER DESCRIPTION OF PROPERTY ADATEL ASE MONTHLY PAYMENT ACCT. # S,CHEDU,LEG` ACQUISITIONS AND DISPOSALS DETAIL Acquisitions and disposals detail of machinery, equipment, furniture and fixtures and computer equipment, and improvements to leased property in the prior year. If there is not enough room below, attach separate Schedule G-1. ACQUISITIONS - ITEMIZE IN DETAIL 100% ORIGINAL COST DISPOSALS - ITEMIZE IN DETAIL YEAR ACQUIRED 100% ORIGINAL COS SCHED,II REAL ESTATE IMPROVEMENTS During the past calendar year, did your business make improvements and/or other additions to real property, owned by your business? If yes, attach a separate schedule H-1 with information on such improvements. C': YES ANO SCHEDULE I `- BILLBOARDS - OUTDOOR ADVERTISING STRUCTURES Does your business own any billboards - outdoor advertising structures? C YES 0 NO If yes, attach separate Schedule 1-1 with requested information. SO4E00LE»3fw} LEASED EQUIPMENT Does your business lease equipment to others?; ` YES 4 NO If yes, attach separate Schedule J-1 with requested information. AFFIRMATION LISTING MUST BE SIGNED BY A LEGALLY AUTHORIZED PERSON - Please check the capacity in which you are signing the affirmation. For Individual Taxpayer: Taxpayer ❑ Guardian ❑ Authorized Agent ❑ Other person having knowledge of and charged with the care of the person and property of the taxpayer. For Corporations, Partnerships, Limited Liability Companies, Unincorporated Associations: JW Principal Officer of the Taxpayer ❑ Full-time employee of the taxpayer who has been officially empowered by a principal officer to Title • xi,, )r list the property and sign the affirmation. Title ❑ Authorized agent. If this capacity is selected, I certify that I have NCDOR Form AV -59 on file for this taxpayer. ❑ Yes ❑ No Under penalties prescribed by law, I affirm that to the best of my knowledge and belief this listing, including any accompanying statements, inventories, schedules, and any other info ation is true and complete. (If this is signed by an individual other than the taxpayer, he affirms that he is familiar with the extent and true y e of all 2ie taxpayer' property subject to taxed in this ounty and that his affirmation is based on all the information of which he has any knowledge.) Li./ si at Date Authorized Agent Address (494�Lourdes Garcia (_,0.5 o-Sqc� C�,_r rc:o. @ tiler .ecm Telephone Number lax M311391311 Fax Number Email Address Any individual who willfully makes and subscribes an abstract listing required by the Subchapter 11 of Chapter 105 of the North Carolina General Statutes which he does not believe to be true and correct as to every material matter shall be guilty of a Class 2 misdemeanor. (Punishable by imprisonment of up to 60 days).