Form Boe-566-J (Front) Rp-978 - Oil, Gas, And Geothermal Personal Property Statement

COUNTY OF LOS ANGELES • OFFICE OF THE ASSESSOR

500 WEST TEMPLE STREET • LOS ANGELES, CA 90012-2770

Telephone: 213.893.0732 • Email: assessor@co.la.ca.us • Website:

Si desea ayuda en Español, llame al número 213.974.3211

RICK AUERBACH

ASSESSOR

20

This statement is not a public document. The

OFFICIAL REqUIREMENT

information contained herein will be held secret by the

OIL, GAS, AND GEOTHERMAL

A report submitted on this form is required of you

Assessor (Code section 451); it can be disclosed only

by section 441(d) of the Revenue and Taxation Code

PERSONAL PROPERTY STATEMENT

to the district attorney, grand jury, and other agencies

(Code). The statement must be completed according

specified in Code section 408. Attached schedules are

to the instructions and filed with the Assessor on or

considered to be part of the statement.

April 1

before ________. Failure to file it on time will compel the

2. LOCATION OF THE PROPERTY:

Assessor’s Office to estimate the value of your property

from other information in its possession and add a penalty

(a separate report must be filed for each property)

of 10 percent as required by Code section 463.

Field name

CAREFULLY READ AND FOLLOW THE

ACCOMPANYING INSTRUCTIONS

1. nAme AnD mAIlInG ADDreSS

Lease name and pool

3. PARCEL NUMBER

Tax rate area

(

)

4. PHONE NUMBER

E-Mail Address (optional)

(Make necessary corrections to printed name and mailing address.)

ASSESSOR’S USE ONLY

PERSONAL PROPERTY

FULL VALUE

5. Supplies (fuel) Type:

Gravity:

Barrels:

Items

ACqUIS.

ORIGINAL

YEAR

COST

6. Office furniture

7. Warehouse stock (parts, tools, equipment, etc.)

8. Yard stock (rods, tubing, casing, etc.)

9. Other (chemicals, unlicensed vehicles, etc.)

10. DECLARATION OF PROPERTY BELONGING TO OTHERS (if none write “none”)

(SPECIFY TYPE BY CODE NUMBER)

Report conditional sales contracts in lines 6-9 as applicable

Year

Year

Description

Cost to

Annual

1. Leased Equipment

4. Vending Equipment

▼

of

of

and Lease or

Purchase

Rent

2. Leased-Purchase Option Equipment

5. Other businesses

Acq.

Mfr.

Identification

New

Number

3. Capitalized Leased Equipment

6. Government-Owned Property

Tax Obligation:

A. Lessor B. Lessee

▼

Lessor’s Name

Mailing Address

Lessor’s Name

Mailing Address

11. Remarks

TOTAL FULL

VALUE

DECLARATION BY ASSESSEE

Note: The following declaration must be completed and signed. If you do not do so, it may result in penalties.

I declare under penalty of perjury under the laws of the State of California that I have examined this property statement, including accompanying schedules, statements or other attach-

ments, and to the best of my knowledge and belief it is true, correct, and complete and includes all property required to be reported which is owned, claimed, possessed, controlled,

or managed by the person named as the assessee in this statement at 12:01 a.m. on January 1, 20 ____.

SIGNATURE OF ASSESSEE OR AUTHORIZED AGENT*

DATE

OWNERSHIP

✍

TYPE (✓)

NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed)

TITLE

Proprietorship

Partnership

NAME OF LEGAL ENTITY (other than DBA) (typed or printed)

FEDERAL EMPLOYER ID NUMBER

Corporation

Telephone number

PREPARER’S NAME AND ADDRESS (typed or printed)

TITLE

Other

( )

BOE-566-J (FRONT) REV. 5 (8-04) RP-978 (Rev. 08/05)

* Agent: See back for Declaration by Assessee instructions.

THIS REPORT SUBJECT TO AUDIT