THE STATE OF TEXAS Harris County Appraisal District
COUNTY OF HARRIS Account Number
Tax Year
Affidavit Concerning Personal Property Use
BEFORE ME, the undersigned authority, on this day personally appeared __________________________ known to me, and who
being by me duly sworn, on oath deposed and said:
"I testify that the following personal property items:
listed in the name of _____________________________________________________________________ a nonprofit
organization, and situated at _____________________________________________________ are not held or used for the
production of income."
"I further testify that for the tax year indicated above: (a) none of the above listed items have been or will be reported to the Internal
Revenue Service as a depreciable business asset or as an asset on which a mileage rate was or will be claimed in lieu of depreciation;
(b) no maintenance, repair, fuel, insurance, or other costs for any of the above listed items have been or will be charged off or claimed
as a business expense for federal income tax purposes; and (c) none of the above items are used in a way that results in accrual of
distributable profits or realization of private gain."
SUBSCRIBED AND SWORN TO before me this the ________ day of _____________________, _________.
INH:AFF:002 (6/10)
Item Item
Exempt item listing continued next page
Affiant's Signature
Typed or Printed Name
Title
Organization Name
IRS Identification Number
Notary Public, State of Texas
address
My Commission Expires
