PDF document

- 1 -

MARK CHURCH
EF-566-D-R08-0810-41000786-1 Assessor - County Clerk - Recorder
BOE-566-D (P1) REV. 08 (08-10) 555 County Center
OIL AND DISSOLVED GAS Redwood City, CA 94063
P 650.363.4500 F 650.599.7435
PRODUCTION REPORT FOR 20___ email assessor@smcacre.org
Declaration of costs and other related property web www.smcacre.org
information as of 12:01 A.M., January 1, 20___. File
a separate report for each property.

1. NAME AND MAILING ADDRESS
(Make necessary corrections to the printed name and mailing address) OFFICIAL REQUIREMENT
A report submitted on this form is required of you by section 441(d) of
the Revenue and Taxation Code. The statement must be completed
according to the instructions and filed with the Assessor on or before
April 1, 20___. Failure to timely file the statement will compel the
Assessor’s Office to estimate the value of your property from other
information in its possession and add a penalty of 10 percent as
required by Revenue and Taxation Code section 463.

TELEPHONE NUMBER: ( )

2. DESCRIPTION OF THE PROPERTY (A separate report must be filed for each property)
FIELD NAME LEASE NAME AND POOL

RECOVERY
PRIMARY OTHER. DESCRIBE:
3. PARCEL NUMBER TAX RATE AREA

4. ZONE OR WELL NUMBER

PRODUCTION DATA INJECTION DATA
CALENDAR YEAR 20___ NUMBER PRODUCING NUMBER INJECTION WATER
OIL WATER GAS STEAM (EXCLUDE
WELLS DAYS WELLS DAYS DISPOSAL)
5. JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
6. JUL-DEC TOTAL
7. YEAR’S TOTAL

(use separate sheets as needed for the following)
8. DEPTH TO ZONE BOTTOM 16. G. & G.L. INCOME, ANNUAL
9. ROYALTY RATE P G 17. GAS USED ON LEASE, MCF/YR
10. OIL GRAVITY, API DEC. 18. GAS SALES, MCF/YR
11. PRICE OF GAS PER MCF, DEC. 19. NGL SALES, GAL/YR
12. HEAT CONTENT - PRODUCED GAS - BTU/MCF 20. TRUCKING CHARGE PER BBL.
13. PRICE OF NGL SOLD PER GAL., DEC. 21. NAME OF CRUDE OIL BUYER
14. CRUDE OIL PRICE PER BBL., DEC. 22. SEVERANCE TAX PER BBL.
15. POSTED OIL FIELD
THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION

- 2 -

Enlarge image

EF-566-D-R08-0810-41000786-2
BOE-566-D (P2) REV. 08 (08-10)
23. PROVED RESERVES
AS OF YEAR END                     100% OIL (BBL)                            100% GAS (MMCF)                                     ASSESSOR’S USE ONLY
DEVELOPED
UNDEVELOPED
24. BASIC WELL EQUIPMENT
                                                         NUMBER OF WELLS
               TYPE
                                   ACTIVE                           IDLE                     DEPTH
PRODUCING FLOWING
PRODUCING ARTIFICIAL LIFT
IDLE WITH EQUIPMENT:         GOOD
IDLE WITH EQUIPMENT:         FAIR
IDLE WITH EQUIPMENT:         POOR
IDLE WITH NO EQUIPMENT
IDLE RODS AND TUBING
OBSERVATION
INJECTION STEAM (NON-CYCLIC)
INJECTION WATER
INJECTION AIR/GAS
WATER DISPOSAL
WATER SUPPLY
                              TOTAL
25. OTHER PRODUCTION EQUIPMENT - ADDITIONS AND REMOVALS
               ITEM                NUMBER      SIZE                 ACQUISITION           ORIGINAL COST 
                                                                    DATE                  INSTALLED
TANKS, WASH
TANKS, LARGE STORAGE
INJECTION EQUIPMENT
DISPOSAL EQUIPMENT
SHIPPING PUMPS
STEAM GENERATORS
SCRUBBERS
COMPRESSORS
LACT

                              TOTAL
26. REMARKS

                                                              DECLARATION BY ASSESSEE
 OWNERSHIP 
      TYPE  ( )R              Note: The following declaration must be completed and signed. If you do not do so, it may result in penalties.
Proprietorship       I declare under penalty of perjury under the laws of the State of California that I have examined this property statement, 
Partnership          including accompanying schedules, statements or other attachments, and to the best of my knowledge and belief it 
Corporation          is true, correct, and complete and includes all property required to be reported which is owned, claimed, possessed, 
Other                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
t
NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed)                                                                         TITLE

NAME OF LEGAL ENTITY (other than DBA) (typed or printed)                                                                         FEDERAL EMPLOYER ID NUMBER

PREPARER’S NAME AND ADDRESS (typed or printed)                                                      TELEPHONE NUMBER             TITLE
                                                                                                    (        )
                                               *Agent:THISSee pageREPORT4 forISDeclarationSUBJECTby AssesseeTO AUDITInstructions.

- 3 -

Enlarge image

EF-566-D-R08-0810-41000786-3
BOE-566-D (P3) REV. 08 (08-10)
INSTRUCTIONS FOR COMPLETING OIL AND DISSOLVED GAS
PRODUCTION REPORT
This report is not a public document. The information contained here will be held confidential by the Assessor (section 451,
Revenue and Taxation Code); it can be disclosed only to the district attorney, grand jury and other agencies specified in section
408 of the Revenue and Taxation Code. Attached schedules are considered to be part of the report. The Assessor’s failure to
keep such records confidential could subject him or her to civil damages (Government Code section 1504), and if such failure is
determined to be willful, the Assessor may be subjected to other sanctions as provided by law (Government Code sections 3060 - 3074).
Agents of the county hired as consultants are subject to the same provisions, sanctions and penalties upon failure to keep records
confidential.

All personal property owned by the respondent and any property belonging to others on the lease as of January 1 must be reported to the
Assessor on BOE-566-J, Oil, Gas and Geothermal Personal Property Statement.

Line numbers listed in these instructions refer to identical line numbers printed on the form. At top of form, fill in the year of lien date for
which this report is made.

LINE 1. NAME, MAILING ADDRESS AND PHONE NUMBER

a. NAME OF OPERATOR (PERSON OR CORPORATION)
If the name is preprinted, check the spelling and correct any error. In the case of an individual, enter the last name first,
then the first name and middle initial. Partnerships must enter at least two names, showing the last name, first name and
middle initial for each partner. Corporation names should be complete so they will not be confused with fictitious or DBA
(Doing Business As) names.
b. DBA OR FICTITIOUS NAME
Enter the DBA name under which you are operating in this county below the name of the sole owner, partnership, or
corporation.
c. MAILING ADDRESS
Enter the mailing address of the legal entity shown in line 1b above. This may be either a street address or a post office
box number. It may differ from the actual location of the property. Include the city, state, and zip code.
d. PHONE NUMBER
Enter the phone number where we may contact you or your authorized representative for information regarding the subject
property.

LINE 2. DESCRIPTION OF THE PROPERTY
Report each lease or parcel on a separate report form. Fill in oil field name, lease name and pool, and lease number.
Conform to Division of Oil and Gas classification in regard to name of field, lease, and pool. Check whether recovery is primary
or other type. If other, describe method, for example, waterflood, steam injection (cyclic or flood), fire flood, etc.

LINE 3. PARCEL NUMBER AND TAX RATE AREA NUMBER
Fill in the parcel number and tax rate area number, if known.

LINE 4. Submit a separate form for each Department of Energy (DOE) “Formation,” for example, Division of Oil and Gas
recognized pool, and label according to the Division of Oil and Gas nomenclature.

LINE 5. Report oil (BBLS), water (BBLS) and gas (MCF) production and steam (BBLS) or water (BBLS) injection by months on a
calendar year basis and the number of producing or injection wells and days. New wells and/or abandonments should be
reported separately.

LINE 9. List the total royalty percent. For leasehold properties check appropriate Box P or G whether the lessor is a private party or a
governmental agency and state the government royalty separately.

LINE 14. Report crude oil price per barrel at the end of December before any transportation charges.

LINE 15. Please list the posted oil field used as a reference for crude oil sales.

LINE 16. Report calendar year’s gas and gas liquids income to the property for working and royalty interests combined (excluding plant’s
share of gas and gas liquids).

- 4 -

Enlarge image

EF-566-D-R08-0810-41000786-4
BOE-566-D (P4) REV. 08 (08-10)

LINE 17. Report gas (MCF) used as lease fuel.

LINE 18. Report volume of gas (MCF) credited to lease after plant processing. This volume should be the same as that upon which
royalty payments are based.

LINE 19. Report volume of (NGL) credited to lease after plant processing. This volume should be the same as that upon which royalty
payments are based.

LINE 20. Indicate trucking charges per barrel if oil must be hauled.

LINE 23. Indicate your proved developed and undeveloped oil and gas reserves (as defined in Rule section 468 of the California Code
of Regulations), as of the year end.

LINE 24. Report the number of wells by type, indicating the status and average depth. Idle with equipment (good, fair, poor), idle no
equipment, and idle rods and tubing pertain to producing wells only. A well is considered active if used at least one day during
December. Active producers and injectors should equal the number of wells reported for December in the production and
injection data. An injector should be reported as a producer if the well was in production at any time during December.

LINE 25. Report additions to or removals of improvements of your “Other Production Equipment.” Label removals. The Assessor may,
on written notice, request annual reporting of previously existing equipment.

LINE 26. Any other information bearing on the value of the property may be recorded under “Remarks.”

DECLARATION BY ASSESSEE
The law requires that this production report, regardless of where it is executed, shall be declared to be true under penalty of perjury under
the laws of the State of California. The declaration must be signed by the assessee, a duly appointed fiduciary, or a person authorized to
sign on behalf of the assessee. In the case of a corporation, the declaration must be signed by an officer or by an employee or agent who
has been designated in writing by the board of directors, by name or by title, to sign the declaration on behalf of the corporation. In the
case of a partnership, the declaration must be signed by a partner or an authorized employee or agent. In the case of a Limited Liability
Company (LLC), the declaration must be signed by an LLC manager, or by a member where there is no manager, or by an employee or
agent designated by the LLC manager or by the members to sign on behalf of the LLC.
When signed by an employee or agent, other than a member of the bar, a certified public accountant, a public accountant, an enrolled
agent or a duly appointed fiduciary, the assessee’s written authorization of the employee or agent to sign the declaration on behalf of
the assessee must be filed with the Assessor. The Assessor may at any time require a person who signs a production report and who is
required to have written authorization to provide proof of authorization.
A production report that is not signed and executed in accordance with the foregoing instructions is not validly filed. The penalty imposed
by section 463 of the Revenue and Taxation Code for failure to file is applicable to unsigned production reports.

PDF file checksum: 1302472637

(Plugin #1/9.12/13.0)