MARK CHURCH
EF-566-J-R06-0806-41000805-1                                                                                     Assessor - County Clerk - Recorder
                                                                                                                 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 
the 
                                                              to estimate the value of your property from 
other 
This statement is not a public document. The information 
                                                          part of the statement.                                 LOCATION OF THE PROPERTY:
CAREFULLY READ  AND FOLLOW THE ACCOMPANYING INSTRUCTIONS                                                         (a separate report must be filed for each property)
1. NAME AND MAILING ADDRESS                                                                                   2. Field

                                                                                                              3. PARCEL NUMBER 
                                                                                                                 Tax rate area 
                                                                                                                                 (     )
                 (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.    Officefurniture

7.    Warehousestock(parts,tools,equipment,etc.)

8.    Yardstock(rods,tubing,casing,etc.)

9.    Other(chemicals,unlicensedvehicles,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                                                         Y        Y       Cost          Annual
             1.LeasedEquipment                                4.VendingEquipment                                               and     Lease     Rent
             2.Leased-PurchaseOption5.              Otherbusinesses                                                     Mfr                  New
                                                                                                                                       Number
             3.CapitalizedLeasedEquipment                     6.Government-OwnedProperty
             Tax     A.      Lessor     B.Lessee
Lessor’s Name
MailingAddress
Lessor’s Name
MailingAddress
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 
                        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
  Other 
                                                                                         (                  )
                                              *Agent: see back for Declaration by Assessee instructions.
                                                              THIS STATEMENT SUBJECT TO AUDIT

EF-566-J-R06-0806-41000805-2

                     INSTRUCTIONS FOR COMPLETING THE OIL, GAS, AND GEOTHERMAL
                                            PERSONAL PROPERTY STATEMENT
Repor
.
LINE 1.  NAME AND MAILING ADDRESS
         a. NAME OF OPERATOR (PERSON OR CORPORATION)
             indivnam
                                                                                                                                  ames.
         b. DBA
            Enter the DBA name under which you are operating in this county below the name of the sole owner,
            or   poration.
         c. MAILINGADDRESS
                  box
            number
LINE 2.  LOCATION OF THE PROPERTY
         .
LINE 3.  PARCEL NUMBER

LINE 4.  PHONE NUMBER
         Enter the phone number where we may contact you or your authorized representative for information regarding
         subjecer    ty.
LINE 5.  SUPPLIES (Used as fuel)
         barrels.
LINES 6  OFFICE EQUIPMENT, WAREHOUSE STOCK, YARD STOCK, OTHER
thru 9.  Enterty.
LINE 10. DECLARATION OF PROPERTY BELONGING TO OTHERS
               nam
            A-Les

         1. LEASED EQUIPMENT. Report the year of acquisition, the year of manufacture, description of the leased property, the lease
                            (see No. 3 below).
         2. LEASE-PURCHASEOPTIONEQUIPMENT.Reporthereallequipmentacquiredonlease-purchaseoptiononwhichthe final pay-
            ment remains to be made.
             r                                                                                                                               If 
            final payment has been made(see No. 3 below).
         3.minimum

            s
         4. VE9.
         5.
         6.      or
               property, and

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
lawsoftheStateofCalifornia.Thedeclarationmustbesignedbytheassessee,adulyappointedfiduciary,orapersonauthorizedtosignonbehalf
oftheassessee.Inthecaseofa corporation,thedeclarationmustbesignedbyanofficerorbyanemployeeoragentwhohasbeendesignated
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
declarationmustbesignedbyapartneroranauthorizedemployeeoragent.Inthecaseofa 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.

 dec

                            Tax