Form Boe-571-L - Business Property Statement For 2005
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32005
BOE-571-L (S1F) REV. 9 (8-04)
BUSINESS PROPERTY
STATEMENT FOR 2005
(Declaration of costs and other related
property information as of 12:01 A.M.,
January 1, 2005)
RETURN THIS ORIGINAL FORM. COPIES WILL NOT BE ACCEPTED.
(Make necessary corrections to the printed name and mailing address.)
FILE RETURN BY APRIL 1, 2005
LOCATION OF THE PROPERTY
STREET
CITY
(File a separate statement for each location.)
PART I:
GENERAL INFORMATION
f.
Enter name and telephone number of authorized person to contact at location of
accounting records:
COMPLETE (a) THRU (g)
a. Enter type of business:
g. During the period of January 1, 2004 through December 31, 2004:
b. Enter local telephone number (
)
FAX number (
)
(1) Has all or part of this real property been subject to a change in ownership?
E-Mail Address (optional)
Yes
No
c. Do you own the land at this business location?
Yes
No
(2) Are any related entities conducting business in the county?
Yes
No
If yes, provide name, mailing address, and locations:
If yes, is the name on your deed recorded
as shown on this statement?
Yes
No
(3) If you leased this real property, has it been the subject of a lease agreement for a
d. When did you start business at this location? DATE:
period of 35 years or more (including options)?
Yes
No
If your business name or location has changed from last year, enter the former name
(4) Did you acquire “control” through acquisition of stock or otherwise of a legal entity
and/or location:
which owns real property in this county?
Yes
No
(5) Did another person or entity acquire “control” through acquisition of stock or
e. Enter location of general ledger and all related accounting records (include zip code):
otherwise of this corporation or entity?
Yes
No
ASSESSOR’S USE ONLY
COST
PART II: DECLARATION OF PROPERTY BELONGING TO YOU
(omit cents)
(attach schedule for any adjustment to cost)
(see instructions)
1. Supplies
2. Equipment
(From line 35)
3. Equipment 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
Year
Description
Cost to
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
Mailing address
10. Lessor’s name
Mailing address
DECLARATION BY ASSESSEE
OWNERSHIP TYPE (3 )
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 accompanying
Partnership
schedules, statements or other attachments, and to the best of my knowledge and belief it is true, correct, and complete and includes all property
Corporation
required to be reported which is owned, claimed, possessed, controlled, or managed by the person named as the assessee in this statement at
Other ______________
12:01 a.m. on January 1, 2005.
SIGNATURE OF ASSESSEE OR AUTHORIZED AGENT*
DATE
BUSINESS
-
DESCRIPTION
(3 )
NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed)
TITLE
Retail
Wholesale
NAME OF LEGAL ENTITY (other than DBA)(typed or printed)
FEDERAL EMPLOYER ID NUMBER
Manufacturer
Service/Professional
PREPARER’S NAME AND ADDRESS (typed or printed)
TELEPHONE NUMBER
TITLE
(
)
* Agent: See page S4B for Declaration by Assessee for instructions.
THIS STATEMENT SUBJECT TO AUDIT
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