.... BOB HUSTON 201SS ASSESSMENT LIST Assessor, Cass County, MO Dear Business Owner I Manager: You are required by law to provide a list, indicating 201 W. Wall S1. Ste B ~ year purchased and original cost lor all tangible personal property, e.g. vehicles, Harrisonville, MO 64701-2396 Computers & 0IIice Equipment, Fumiture, FIXtures, Manufacturing Equip. & Tooling, etc.,

belonging to you or under the control of your company in Cass County, Missouri, on Jan. Phone: 816-380-8400

AVOID PENALTY Return b March 1st

Physical Location:

1st. CornpIete this form, sign and retum ~ before March 151 to avoid penalty. Follow instructions below and on back.

111..111 •••1.1..11 II1111111111.11111. II1111111111.11.111111 •• 1111 BOB HUSTON CASS COUNTY ASSESSOR 201 W WALL ST STE B HARRISONVILLE MO 64701-2396

ASSESUD VALUE PENAI.TY ASSESSEDJ'ALUE . PENAL~ 0-$1,000 $10 $5,001 - $6,000 $60

$1,001 - $2,000 $20 $6,001 - $7,000 $70 $2,001 - $3,000 $30 $7,001 - $8,000 $80 $3,001 - $4,000 $40 $8,001 - $9,000 $90 $4,001 - $5,000 $50 $9,001 and above $100

CONFIRM ACTUAL PHYSICAL LOCATION AND TELEPHONE NUMBER OF PROPERTY COVERED BY THIS RETURN NOT P.O. BOX Street Address I City I State I Zip Code I ( Telep)one

INSTRUCTIONS: 1.) Review all vehicles, equipment and property listed below. (These appeared on your previous year's assessment list). 2.) Draw a line through any Items you did NOT own!hold on January 1st. 3.) List any NEW ITEMS not shown in this box in the appropriate sections below or on back and mark the "ChanglS" box below before signing. 4.) If the description of an item is incorrect, draw a line through that item and re-list it in the appropriate section below. 5.) If you still own everything on the list and have not purchased any new property, mark the "No Changes" box below this section, and sign and date where indicated.

PIeBse check lHM of these boxes. Sign on back before returning to assessor.

D CHANGES HAVE BEEN MADE D NO CHANGES MADE I (we) de1BtfKlltsms above or added Items below No new property owned on Jan. 1st

ATTEIITIONI Ust property by type indicating year purchased and original cost for all business equipment including Vehicles, Large Equipment, Computers & Office Equipment, Furniture & Fixtures, Manufacturing Equipment & Tooling, etc. This list is subject to audit. To assure a fair and accurate assessment of your equipment, and to avoid listing each item on this form, PLEASE ATTACH YOUR COMPANY'S COMPLETE AMORTIZATION SCHEDULE.

TOTAL YEAR Computers, PerIpherals OffIce Furniture, Manufacturing Equip. Dies, Molds, Jigs ConstructIon Equip. Professional, Medical PURCHASE PURCHASED • Telephone Equip. Axturea & Equip. and Machinery Special Tooling & Machinery Dental & Lab Equip• PRICE OF BUSINESS 2011

ITEMS 2010

2009

~ 2008 2007

2006

PRIOR YEARS

TOTAL PURCHASE

YEAR PURCHASED

Store, Restaurant & Bar Equipment

Household goods for Hotel, Motel, Apt. Rental

·Servlce Station, Bulk Plant, Car Wash Equip.

Video Movies, Tapes GamelVend Machines

Equip. owned by you and leased to others

OTHER: e.g. Pollution Contr. EqUip., Signs, etc.

PRICE OF BUSINESS

2011

ITEMS 2010

2009

~ 2008 ·See back aide 2007

for Service Station 2006 Equip.

PRIOR YEARS

YR. ACQUIRED ACQUISITION COST ASSESSOR'S USE LEASED PERSONAl PROPERTY SUMMARY

LEASED EQUIPMENT

2011

2010

Please list below any leased or rented equipment in your possession. The terms of your lease or rental contract may determine tax liability. This section is designed to ensure that the property is assessed to the proper owner. You may wish to attach a separate list or a copy 01 your lease.

2009 LESSOR'S NAME AND ADDRESS

2008

2007 LENGTH OF LEASE ITEM

2006 DATE OF LEASE MONTHLY RENT

019BCASS2-107 PRIOR YEARS

CONTINUED ON BACK •

TeresaText Box2011

CARS, VANS & SUVs

YEAR MAKE (Chev., Ford, etc.) MODEL (Lumina, Taurus, etc.) SERIES (SL, SE, etc.) # ODORS (CIRCLE ONEI

2WD 4WD AWD

2WD 4WD AWD

VIN (Vehicle 10 Number)

HISTORIC VEH. YEAR MAKE MODEL

HISTORIC PLATES: DYES DNO

TONS (CIRCLE ONE) EXT CAB

EST. VALUE:

DIESEL VIN (Vehicle 10 Numberl

PICKUPS 2WD 2WD

4WD

4WD

YES

YES

NO

NO

YES

YES

NO

NO

TRUCKS & SEMI

TRACTORS

YEAR MAKE (Sterling, Mack, etc.) MODEL GROSSVEH WEIGHT BODY TYPE (Flatbed, Grain) MO MILES TOTAL MILES VIN (Vehicle 10 Number)

SEMI TRAILERS

CAMPER TRAILERS

YEAR

YEAR

MAKEI MODEL

MAKE

TYPE {Reefer Flat Van Tanker Etc.\ I AXLES ILENGTH MO MILES I I

MODEL TYPE (CIRCLE ONEI

5TH WHEEL UPRIGHT FOLD DOWN HI/LOW

TOTAL MILES

LENGTH

VIN (Vehicle 10 Number)

VIN (Vehicle 10 Number)

TRAILERS YEAR MAKE TYPE (Stock, Flat, Horse, Etc.) AXLES LENGTH VIN (Vehicle 10 Number)

List BOAT -

Trailers below

BOAT TRAILERS

WATERCRAFT, BOATS

YEAR

YEAR

MAKE

MAKE MODEL

MODEL &TYPE AXLES

TYPE (Bass, Jon) IMATERIAL (Circle One)

I Fiber Alum. Wood

LENGTH

LENGTH

VIN (Vehicle 10 Number)

VIN I SERIAL NUMBER

BOAT MOTORS YEAR MAKE MODEL TYPE (Circle Onel

inboard Outboard

HP VIN I SERIAL NUMBER

BUSES YEAR MAKE I CHASSIS MODEL I SERIES LENGTH # PASSENGERS VIN (Vehicle 10 Number)

MOTOR HOMES & RVs

YEAR MAKE I CHASSIS MODEL LENGTH SERIES VIN (Vehicle 10 Number)

MOTORCYCLES &ATVs

AIRPLANES

MOBILE HOMES

YEAR

YEAR

YEAR

LOCATION:

MAKE

MAKE

MAKE

MODEL

MODEL

MODEL

ITYPE (Circle One)

I JET PROP

I WIDTH

# OF WHEELS CC/HP

MAX. CERTIFIED GROSS HRS. FLOWN I PURCHASE TAKEOFF WEIr,HT LASTYEAR PRICE

1$I LENGTH I DETERMINED BY:

o TITLE 0 MEASUREMENT

VIN (Vehicle 10 Number)

VIN (Vehicle 10 Number)

VIN (Vehicle 10 Number)

TYPE NUMBER TYPE NUMBER TYPE NUMBER TYPE NUMBER TYPE NUMBER

COWS/BULLS BARROWS/GILTS EWES HORSES POULTRY

LIVESTOCK CALVES SOWS FEEDER LAMBS MULES BEE COLONIES

YEARLINGS PIGS SLAUGHTER LAMBS GOATS EXOTICS & OTHER

BRUSH HOG YEAR MAKE MODEL SIZE NUMBER OF

FARM MACH.

COMBINE

BALER

TRACTOR

OTHER

ROAD GRADER ROAD SCRAPER

YEAR MAKE MODEL SIZE NUMBER OF

BACK HOE

OTHER MACH.

HIGHLOADER

FORKLIFT

OTHER

POLLUTION CONTROL EQUIP.

If located in the Enterprise Zone answer 1, 2 and 3: 2. Cost of tools and equipment used in retooling to introduce new product line or to make improvements to an existing product line. 1. Cost of tools and equipment used for pollution control. 2011 Acquisition Date Cost $ Product Line _

2011 Acquisition Date Cost $ _ 2010 $ _ 2010 $ _

2009 $ _ 2009 $ _

2008 $ _ 2008 $ _ 2007 $ _ 2007 $ _ 2006 $ _ 2006 $ _

Prior to 2006 $ _ Prior to 2006 $ _

3. List your standard industrial classification (SIC):

*SERVICE DESCRIPTION NO. OR QUANTITY ASSESSOR'S USE DESCRIPTION NO. OR QUANTITY ASSESSOR'S USE STATION PUMPS - SINGLE COMPUTING TANKS (Capacity in Gallons)

EQUIPMENT PUMPS - DOUBLE COMPUTING PEDESTAL EXTERIOR LIGHTS

OWNER PUMPS - BLENDER PEDESTAL INTERIOR LIGHTS OF

EQUIPMENT HOISTS REVOLVING INTERIOR LIGHTS

ONLY AIR COMPRESSORS HIGHRISE SIGNS

AGENT OR PREPARER'S INFORMATION NAME ADDRESS

CITY, STATE, ZIP CODE ?LEPHONE) I TAX I.D. NUMBER

i, 0 President 0 Treasurer 0 Owner 0 Manager 0 Other _ of do hereby certify that the foregoing list 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, 2012. 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.

Signed Date o I have listed additional property on sheet attached.

FORM CASS2· 107 019 B