Annual Return to Providence, R.I. Tax Assessor
The Law is Mandatory - A Return Must Be Filed (RI Law Section 44-5-15, as amended)
And Mail To: Tax Assessor, City Hall Room 208, Providence, RI 02903
401-421-5900
Statement of Valuation as of 12/31/2012
For your convenience, we have supplied you with this form for the declaration of taxable property located in Rhode Island. Ac-
cording to The General Laws Of Rhode Island, taxable property must be declared to the Assessor between DECEMBER 31, 2012
and JANUARY 31, 2013. If a taxpayer is unable to make such a declaration within the prescribed time, they may submit written
notice, prior to JANUARY 31, of intention to submit declaration by MARCH 15
prescribed time, eliminates the right to appeal. No amended returns will be accepted after MARCH 15th.
STATE LAW REQUIRES THE FILING OF THIS DECLARATION. FAILURE TO DO SO MAY RESULT IN AN IN-
CREASED ASSESSMENT. THIS FORM IS NOT SUBJECT TO PUBLIC INSPECTION.
Ownership: ❑ ❑ ❑ Individual
NAME(S): _______________________________________________________________________________
Business Name/ DBA: _______________________________________________________________________________
Business Address: ___________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
SECTION 10 LEASEHOLD IMPROVEMENTS
Fixtures, etc. owned by you and attached to or used in real estate owned by others and not reported elsewhere. Lease-
Calendar Year
Purchased
Description of
Improvement
Improvement
Cost
Depreciation
Rate
Assessor’s Use
Only
SECTION 11 SIGN YOUR RETURN AND NOTARIZE
I do hereby certify and declare that, to the best of my knowledge and belief, the foregoing is a true and complete list of all real estate and personal
2020
Please
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Signature Date Title
I _______________________________________
________________________________________
(Title) am responsible for the information
contained within this form
________________________________________
________________________________________
________________________________________
My Residence Address is:
(Name)
Give a Full, General Description of Your Business Operation:
❑ Mfg. ❑ Wholesale ❑ Retail ❑ Other:
Do you own or lease the space occupied? ______________ Monthly Rent: ________________________
SECTION 1 REAL ESTATE OWNED
Assessor’s
Land Improvements
If You Need Additional Space Attach Addendum
Claimed
Full Value
2020
2019
2018
2017
2016
2015
2014
2013
TOTALS
On ___________________________, __________________________ personally appeared before me and made oath that the
foregoing account, by him/her signed and exhibited, contains to the best of his/her knowledge and belief, a true and full account and
valuation of all the ratable estate owned or possessed by said corporation, co-partnership, or individual.
Please attach a list disposed items with this signed form. Include date of disposal and method of disposal and sign below to
acknowledge the attachment.
This Name and Mailing Address
Will Be Used For Tax Bill.
➛
Signature
Date
IF YOU HAVE GONE OUT OF BUSINESS DURING THE 2020 CALENDAR
YEAR, PLEASE FILL OUT THE SECTION BELOW.
Date of Business Closure _______________ Were the assets sold (circle): Y / N
Buyer Name: _________________________ Buyer Address: ____________________________
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