THE STATE OF TEXAS Harris County Appraisal District

COUNTY OF HARRIS Account Number

Tax Year

Affidavit Concerning Personal Property UseBEFORE 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