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MARK CHURCH
EF-566-J-R06-0806-41000806-1 Assessor - County Clerk - Recorder
BOE-566-J (FRONT) REV. 6 (8-06)
555 County Center
20____ OIL, GAS, AND GEOTHERMAL Redwood City, CA 94063
PERSONAL PROPERTY STATEMENT P 650.363.4500 F 650.599.7435
email assessor@smcacre.org
OFFICIAL REQUIREMENT web www.smcacre.org
A report submitted on this form is required of you by section 441(a) of the Revenue and Taxation Code (Code).
The statement must be completed according to the instructions and filed with the Assessor on or before April
1, 20____. Failure to file it on time 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 Code section 463.
This statement is not a public document. The information contained herein will be held secret by the Assessor
(Code section 451); it can be disclosed only to the district attorney, grand jury, and other agencies specified in LOCATION OF THE PROPERTY:
Code section 408. Attached schedules are considered to be part of the statement.
CAREFULLY READ AND FOLLOW THE ACCOMPANYING INSTRUCTIONS (a separate report must be filed for each property)
1. NAME AND MAILING ADDRESS 2. Field name
Lease name and pool

3. PARCEL NUMBER
Tax rate area
4. PHONE NUMBER ( )
(Make necessary corrections to printed name and mailing address) E-Mail Address (optional)
PERSONAL PROPERTY ASSESSOR’S USE ONLY
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 attachments, 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
PREPARER’S NAME AND ADDRESS (typed or printed) TELEPHONE NUMBER TITLE
Other
( )
* Agent: see back for Declaration by Assessee instructions.
THIS STATEMENT SUBJECT TO AUDIT

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EF-566-J-R06-0806-41000806-2
BOE-566-J (BACK) REV. 6 (8-06)
INSTRUCTIONS FOR COMPLETING THE OIL, GAS, AND GEOTHERMAL
PERSONAL PROPERTY STATEMENT
Report all personal property owned by the respondent and any property belonging to others on the lease as of January 1.
Line numbers listed in these instructions refer to identical line numbers printed on the form.
LINE 1. NAME AND MAILING ADDRESS
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 1a 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.
LINE 2. LOCATION OF THE PROPERTY
Fill in the lease and field name. Conform to State Division of Oil and Gas classification in regard to names of fields and pools. For
geothermal properties, ignore term “pool,” and fill in “operating unit” if this term applies.
LINE 3. PARCEL NUMBER
Fill in the parcel number and tax rate area number, if known.
LINE 4. PHONE NUMBER
Enter the phone number where we may contact you or your authorized representative for information regarding the
subject property.
LINE 5. SUPPLIES (Used as fuel)
Enter the type of fuel, A.P.I. gravity, and the number of
barrels.
LINES 6 OFFICE EQUIPMENT, WAREHOUSE STOCK, YARD STOCK, OTHER
thru 9. Enter the year acquired, if known, the cost, and a description sufficient to identify the property.
LINE 10. DECLARATION OF PROPERTY BELONGING TO OTHERS
If property belonging to others, or their business entities, is located on your premises, report the owner’s name and mailing
address. If it is leased equipment, read your agreement carefully and enter the type by Code and whether A-Lessor or B-Lessee
has the tax obligation. For assessment purposes, the Assessor will consider, but is not bound to, the contractual agreement.
1. LEASED EQUIPMENT. Report the year of acquisition, the year of manufacture, description of the leased property, the lease
contract number or other identification number, the total installed cost to purchase (including sales tax), and the annual rent; do not
include in lines 6-9 (see No. 3 below).
2. LEASE-PURCHASE OPTION EQUIPMENT. Report here all equipment acquired on lease-purchase option on which the final pay-
ment remains to be made. Enter the year of acquisition, the year of manufacture, description of the leased property, the lease
contract number or other identification number, the total installed cost to purchase (including sales tax), and the annual rent. If
final payment has been made, report full cost in lines 6-9, as applicable (see No. 3 below).
3. CAPITALIZED LEASE EQUIPMENT. Report here all leased equipment that has been capitalized at the present value of the minimum
lease payments on which a final payment remains to be made. Enter the year of acquisition, the year of manufacture, description of the
leased property, the lease contract number or other identification number, and the total installed cost to purchase (including
sales tax). Do not include in lines 6-9 unless final payment has been made.
4. VENDING EQUIPMENT. Report the model and description of the equipment; do not include in lines 6-9.
5. OTHER BUSINESSES. Report other businesses on your premises.
6. GOVERNMENT-OWNED PROPERTY. If you possess or use government-owned land, improvements, or fixed equipment, or
government-owned property is located on your premises, report the name and address of the agency which owns the property, and
a description of the property.
DECLARATION BY ASSESSEE
The law requires that this property statement, 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 property statement and who is required to have written
authorization to provide proof of authorization.
A property statement 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 property statements.

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