Form Boe-571-L - Business Property Statement - 2016

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William F. Rousseau
BOE-571-L (P1) REV. 21 (05-15)
BUSINESS PROPERTY
Clerk-Recorder-Assessor
STATEMENT FOR 2016
585 Fiscal Dr., Room 104
Santa Rosa, CA 95403
(Declaration of costs and other related
property information as of 12:01 A.M.,
(707) 565-1330
January 1, 2016)
FILE RETURN BY APRIL 1, 2016
Required: Assessment Number:
NAME AND MAILING ADDRESS
(Make necessary corrections to the printed name and mailing address)
Business Address:
RETURN THIS ORIGINAL FORM. COPIES WILL NOT BE ACCEPTED.
FILE A SEPARATE STATEMENT FOR EACH LOCATION.
PART I:
GENERAL INFORMATION
COMPLETE (a) THRU (g)
f.
Enter name and telephone number of authorized person to contact at location of
a. Enter type of business:
accounting records:
b.
Enter local telephone number
FAX number
g. During the period of January 1, 2015 through December 31, 2015:
Email Address
c. Do you own the land at this business location?
Yes
Yes
No
(1) Did any individual or legal entity (corporation, partnership, limited liability company,
If yes, is the name on your deed recorded
etc.) acquire a "controlling interest" (see instructions for definition) in this business
entity?
Yes
No
as shown on this statement?
Yes
No
(2) If YES, did this business entity also own "real property" (see instructions for definition)
d. When did you start business at this location? DATE:
in California at the time of the acquisition?
Yes
No
If your business name or location has changed from last year, enter the former name
and/or location:
(3) If YES to both questions (1) and (2), filer must submit form BOE-100-B, Statement of
Change in Control and Ownership of Legal Entities, to the State Board of Equalization.
See instructions for filing requirements.
e. Enter location of general ledger and all related accounting records (include zip code):
ASSESSOR’S USE ONLY
PART II: DECLARATION OF PROPERTY BELONGING TO YOU
COST
(omit cents)
(attach schedule for any adjustment to cost)
(see instructions)
1. Supplies
2. Equipment
(From line 35)
3. Equipment out on lease, rent, or conditional sale to others
(Attach Schedule)
4. Bldgs., Bldg. Impr., and/or Leasehold Impr., Land Impr., Land
(From line 71)
5. Construction In Progress
(Attach Schedule)
6. Alternate Schedule A
(See instructions)
7.
8.
PART III: DECLARATION OF PROPERTY BELONGING TO OTHERS – IF NONE WRITE “NONE”
(SPECIFY TYPE BY CODE NUMBER)
Year
Cost to
Year
Description
Annual
Report conditional sales contracts that are not leases on Schedule A
of
of
and Lease or
Purchase
Rent
1. Leased equipment
4. Vending equipment
t
Acq.
Mfr.
Identification
New
2. Lease-purchase option equipment
5. Other businesses
Number
3. Capitalized leased equipment
6. Government-owned property
Tax Obligation:
A. Lessor
B. Lessee
t
9. Lessor’s name
Maili
ng address
10. Less
or’s name
Maili
ng address
DECLARATION BY ASSESSEE
OWNERSHIP TYPE (R)
Proprietorship
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
Partnership
accompanying schedules, statements or other attachments, and to the best of my knowledge and belief it is true, correct, and complete and includes all
Corporation
property required to be reported which is owned, claimed, possessed, controlled, or managed by the person named as the assessee in this statement
Oth
er ____
_______
___
at 12:01 a.m. on January 1, 2016.
BU
SINESS
SIGNATURE OF ASSESSEE OR AUTHORIZED AGENT*
DATE
t
DES
CRIPTION
(R)
Retail
NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed)
TITLE
Wholesale
Manufacturer
NAME OF LEGAL ENTITY (other than DBA) (typed or printed)
FEDERAL EMPLOYER ID NUMBER
Service/Professional
PREPARER’S NAME AND ADDRESS (typed or printed)
TELEPHONE NUMBER
TITLE
(
)
*Agent: See page 7 for Declaration by Assessee instructions.
THIS STATEMENT SUBJECT TO AUDIT
INFORMATION PROVIDED ON A PROPERTY STATEMENT MAY BE SHARED WITH THE STATE BOARD OF EQUALIZATION

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