MARK CHURCH
EF-566-D-R08-0810-41000785-1                                                                            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

EF-566-D-R08-0810-41000785-2
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:THISSeeREPORTpage 4forISDeclarationSUBJECTby AssesseeTO AUDITInstructions.

EF-566-D-R08-0810-41000785-3
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).

EF-566-D-R08-0810-41000785-4
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.