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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Telephone Number
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Our Records Indicate That You Are the Holder of the Claim(s) Listed:
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Have Any of the above Claim(s) Been Quitclaimed or Abandoned by You?
YesNo
If yes, which ones?
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If You Acquired or Sold any of Your Claim(s) Since January 1 of Last Year, List Those Purchased or Sold and the Purchase or Sale Price.
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Has Your Claim(s) Been Mined at Anytime in the Past?
YesNo
If yes, when?
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If Not Mined in the Past Year, Why Not?
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OPERATING STATEMENT (2016)
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Assessor's Parcel or Billing No. (if known)
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Are Any of Your Claim(s) Patented?
YesNo
If yes, which one(s)?
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Has the Notice of Assessment Work and Intent to Hold your Claim(s) Been Filed With the Federal Bureau of Land Management by Last December 30th?
YesNo
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If Your Claim(s) is Located Within the Boundaries of a National Forest, Have You Filed Notice(s) on Intention to Operate Your Claim(s)?
YesNo
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Are There Any Buildings or Machinery on Any of Your Claim(s)?
YesNo
BUILDINGS OR MACHINERY ON CLAIMS
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 S2 for Declaration by Assessee instructions.
