Form Atd-39 - Personal Property For Drilling/well Service Workover/seismic Rigs 2003 Page 4

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LESSOR INFORMATION
NAME OF OWNER________________________________________________________________
ADDRESS________________________________________________________________________
CITY____________________________________________STATE____ ZIP____________________
Description of leased equipment
UNITS OR FOOTAGE
MAKE
MODEL
SIZE
DESCRIPTION
AGE
CONDITION
LESSOR INFORMATION
NAME OF OWNER_________________________________________________________________
ADDRESS________________________________________________________________________
CITY_____________________________________________STATE ____ZIP___________________
Description of leased equipment
UNITS OR FOOTAGE
MAKE
MODEL
SIZE
DESCRIPTION
AGE
CONDITION
DECLARATION
W .S. 39-13-107 (a) (i): I, ____________________________, (type or print), the owner of
(or agent, etc., as the case may be) do solemnly swear (or affirm) that the above and
foregoing listed property is a full, true, correct and complete list of all property owned by me
or under my control as agent or otherwise, and that I have not failed or neglected to list for
taxation for the year _ _ _ _, all property of which I am owner or of which I have control as
agent, guardian, administrator or otherwise, in the county of ____________________, State
of Wyoming, and that I have not connived at any violation or evasion of the requirements of
law in relation to the assessment of property for taxation.
W.S. 18-3-205 (b): Any person who fails to return any taxable property owned by him or
under his control is guilty of a misdemeanor and upon conviction shall be fined not
exceeding five hundred dollars ($500.00), imprisoned in the county jail not exceeding ninety
(90) days, or both.
SIGN HERE ______________________________ _______________ _________
Authorized Signature
Title
Date
PHONE NUMBER: _____________________________
ATD-39
3
Revised 12/03

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