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, 2016 . 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 Code section 408. Attached schedules are considered to be part of the statement.
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2
Location of the property
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Parcel Number
4
Phone Number of Person Completing Form
5a
STATEMENT OF LAST CALENDAR YEAR’S OPERATION
5b
STATEMENT OF LAST CALENDAR YEAR’S OPERATING COSTS*
Depth to Groundwater from Original or Natural Surface Level
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Estimated Date for Beginning Mining Operations on Property Owned by You or Under Lease but Not Now Being Mined
12
Current Design Capacity of Plant: Tons/Hours
or Cu.Yds./Hour
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State All Additional Income Other Than Above Derived From This Property Such as Gold Extraction, Asphalt Plant Sites, Ready Mix Plant Sites, Open Storage, Etc.
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Name of All Mineral Products Mined and Sold Last Year (other than those listed in 5a, such as gold):
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Are You the
OwnerLessee orLessor of this Property?
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If the Property Is Under Lease, What Is the Date of the Last Lease Agreement?
Has the Lease Been Amended Since this Date?
YesNo
Is There More Than One Active Lease Agreement?
YesNo
Is This Property in Whole or in Part a Government Lease?
YesNo
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If the Property Is Under Lease, What Is the Date of the Last Royalty Agreement?
Has the Royalty Agreement Been Amended Since This Date?
YesNo
Total Royalty Paid Last Year: $
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Total Rental Paid Last Year: $
Note: If the lease or royalty agreement has been renegotiated since JANUARY 1 last year, attach a copy to this report.
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Use-Restrictions Affecting Value
Use Permit Number
Date
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Has an Environmental Impact Report been Filed on this Property?
YesNo
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Remarks
DECLARATION BY ASSESSEE
OWNERSHIP TYPE
Proprietorship
Partnership
Corporation
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 production report, 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 production and 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, 2016.
*Agent: see page S2B for Declaration by Assessee instructions.
