Form Atd40 - Oil & Gas Field Equipment Personal Property-Owned Declaration Schedule For 2012 Page 4

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Form ATD40
State of Wyoming,
Page
OIL & GAS FIELD EQUIPMENT
PERSONAL PROPERTY—OWNED
DECLARATION SCHEDULE FOR 2012
County Number
Parcel #
Act Number
Personal Prop. Type
DO NOT USE - FOR ASSESSORS USE ONLY
Date received:
By:
Name and address of personal property listed here: (please make any corrections here)
Please indicate location of personal property: (please make any changes here)
1/4 __________ 1/4 __________ Section __________ Township __________ Range __________
Type of land this personal property is located on: (check one) [
]
Private
[
]
Public
Please list all leased equipment and provide owner’s name and address Please list only one location per form.
NAICS CODE: ___________________
Do not report depreciated costs. Please include freight & all installation costs (duplicate form as necessary)
Property Description
Owner and Address
Cost of Leased Property
Condition
Term
Annual Rent
Make / Model / Size / Serial #
of leased property
(From - To)
W.S. 39-13-107 (a)(i) I...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 2012, all
property of which I am the owner of 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.
Type or print your name here: _______________________________________________________________________________________________________
Signature of owner/agent___________________________________________________ Title ________________________Date _______________________
Telephone number ____________________________ Fax Number ___________________________________ Email: _______________________________

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