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.
1
2
Location of the property
3
Parcel Number
4
Phone Number of Person Completing Form
5a
Statement of Last Calendar Year's Mine Operation
5b
Statement of Last Calendar Year's Processing or Milling Operation
5c
Statement of Last Calendar Year's Operating Costs*
6
Estimated Date for Beginning Mining Operations on Property Owned by You or Under Lease but Not Now being Mined
7
a. Ore cut-off grade
b. Current recovery factor
8
COMPANY RESERVES IN ALL CATEGORIES
9
Are You the
Owner orLessee of this Property
(If you own part and lease part check here.)
10
Is This Property in Whole or Part:
A. Government Lease?
YesNo
B. Unpatented Claims?
YesNo
(If yes, list claims under item 17.)
11
If the Property Is Under Lease What Is the Date of the Last Lease Agreement?
Has the Lease Been Amended This Date?
YesNo
Total Rental Paid Last Year $
12
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 $
Note: If the lease or royalty agreement has been renegotiated since January 1 last year, attach a copy to this report.
13
Are Any Other Fees Paid for Property Usage Other Than Those Shown Above?
14
Use - Restrictions Affecting Property Value
15
Has an Environmental Impact Report Been Filed on This Property?
YesNo
(If filed in past year, attach copy)
16
BUILDINGS OR LEASEHOLD IMPROVEMENTS: (enter additions or retirements of your buildings or leasehold improvements since January 1 last year)
17
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.
