N ( ) - Los Angeles County Assessor Page 2
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3BOE-577 (P2) REV. 06 (5-16) M-30 (REV. 8-16)
PLEASE ENTER INFORMATION AS OF JANUARY 1 OF THIS YEAR.
SECTION 1: (continued)
:
AIRFRAME HOURS
FOR HELICOPTERS - HOURS SINCE MAJOR OVERHAUL:
ENGINE(S)
SINGLE
LEFT
RIGHT
ENGINE
MAIN ROTOR
MAIN ROTOR
MAKE
BLADES
HEAD ASSEMBLY
MODEL
MAST
MAST
TAIL ROTOR
YEAR OF MANUFACTURE
TRANSMISSION
DRIVESHAFT
TAIL ROTOR
TAIL ROTOR HUB
TAIL ROTOR
HORSEPOWER
GEARBOX
ASSEMBLY
BLADES
HOURS SINCE NEW
SERVOS
MISCELLANEOUS
HOURS SINCE MAJOR OVERHAUL
TIME BETWEEN OVERHAULS (TBO)
HOURS SINCE MIDLIFE
DATE OF MAJOR OVERHAUL
DATE OF LANDING GEAR OVERHAUL
ENGINE MAINTENANCE SERVICE PROGRAM:
YES
NO
NAME OF PROGRAM:
ENROLLMENT DATE:
FOR HOMEBUILT, KIT, OR EXPERIMENTAL AIRCRAFT, ENTER EXACT DATE OF FIRST FLIGHT:
SECTION II: COMPLETE IF FIRST TIME FILING OR IF ANY CHANGES WITHIN THE LAST CALENDAR YEAR
NAME AND ADDRESS OF OWNER IF DIFFERENT FROM FAA REGISTERED OWNER
NAME
ADDRESS
CITY
STATE
ZIP CODE
COUNTY
IF AIRCRAFT WAS SOLD, ATTACH A COMPLETE COPY OF THE SALES CONTRACT
DATE OF SALE
SALE PRICE
IF SOLD OR DONATED:
$
NEW OWNER NAME
ADDRESS
CITY
STATE ZIP CODE
COUNTY
IF:
MOVED
JUNKED
PARTED
DESTROYED
ABANDONED
NEW LOCATION (IF MOVED)
DATE
COUNTY
EXPLANATION
AIRCRAFT NOT HABITUALLY BASED IN THIS COUNTY
AIRPORT/FBO WHERE NORMALLY KEPT
HANGAR/TIE-DOWN NO.
CITY
STATE ZIP CODE
COUNTY
CHECK REASON AIRCRAFT IS OR WAS IN THIS COUNTY:
REPAIRS
FOR SALE
IN TRANSIT TO:
OTHER:
ATTACH STATEMENT REGARDING ANY ADDITIONAL INFORMATION YOU FEEL WOULD ASSIST US IN VALUING
YOUR AIRCRAFT. IF OWNERSHIP TYPE IS LLC, PLEASE ATTACH A LIST OF MEMBER NAMES.
OWNERSHIP TYPE (R)
DECLARATION BY ASSESSEE
Proprietorship
Note: The following declaration must be completed and signed. If you do not do so, it may result in penalties.
Partnership
I certify (or declare) under penalty of perjury under the laws of the State of California that I have examined this property
Corporation
statement, including accompanying schedules, statements or other attachments, and to the best of my knowledge and belief it
Other
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, 2017.
SIGNATURE OF ASSESSEE OR AUTHORIZED AGENT*
DATE
t
NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed)
TITLE
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
(
)
E-MAIL ADDRESS
* AGENT: SEE INSTRUCTIONS FOR DECLARATION
THIS STATEMENT IS SUBJECT TO AUDIT
BY ASSESSEE.
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