Boe-501-La - Occupational Lead Poisoning Prevention Fee Return For Category "A" Or "B" Reporting
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1
2STATE OF CALIFORNIA
BOE-501-LA (FRONT) REV. 19 (4-13)
BOARD OF EQUALIZATION
OCCUPATIONAL LEAD POISONING PREVENTION FEE RETURN
BOE USE ONLY
FOR CATEGORY "A" OR "B" REPORTING
RA-B/A
AUD
REG
DUE ON OR BEFORE
RR-QS
FILE
REF
YOUR ACCOUNT NO.
[
]
FOID
EFF
BOARD OF EQUALIZATION
SPECIAL TAXES AND FEES
PO BOX 942879
SACRAMENTO CA 94279-6029
READ INSTRUCTIONS
BEFORE PREPARING
All employers in industries for which there is evidence of a potential for lead poisoning are required to file the Occupational Lead
Poisoning Prevention Fee Return. This return is being sent to you because you were identified by the California Department of Public
Health (CDPH) as being in one of these industries.
SECTION I
Complete this section if you are requesting a fee waiver. Please note: You are required to check box 1 and box 1A or 1B, and enter the
number of employees in box 2. A fee waiver application and instructions will be sent to you by the CDPH after this return is received and
processed by the Board of Equalization (BOE). The BOE does not mail or approve fee waiver applications. Indicate any corrections to your
address above.
1.
I will request a fee waiver because lead or lead-containing materials were not present or were present in de minimus (minimal) amounts
at any California site of my business operation during the calendar year. I understand that if I do not complete a waiver application
within 180 days following the due date of this return, or if a waiver is not granted, the fee plus applicable interest is due.
Select type of application: A.
Send instructions for applying electronically via the Internet or B.
Send a paper application
If you checked the box to request a fee waiver, do the following:
Use this box to enter the total number of your employees at all California locations (see Definitions in the Instructions on
2.
the back of this return).
Sign and date this return and send it to the address above. Maintain a copy for your records. The filing of this return is required, and does
not constitute a fee waiver.
SECTION II
Complete this section if you are not requesting a fee waiver. The fee category (A or B) that is applicable to your business is shown above
with your SIC code.
B
C
A
AMOUNT OF
AMOUNT OF
NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN
FEE
FEE DUE
Category A:
(Complete only if you are in Category A)
1. Less than 10 employees (if less than 10 employees, check box at right)
1.
$
$
2. 10 to 99 employees
2.
3. 100 to 499 employees
3.
4.
500 or more employees
4.
Category B:
(Complete only if you are in Category B)
$
5. Less than 10 employees (if less than 10 employees, check box at right)
5.
$
6. 10 to 99 employees
6.
7. 100 to 499 employees
7.
8. 500 or more employees
8.
9.
Enter the total fee due (amount from line 2, 3, or 4 for Category A or line 6, 7, or 8 for Category B)
9. $
10. Penalty [multiply line 9 by 10% (0.10) if payment is made after the due date shown above]
10. $
PENALTY
11.
INTEREST: One month's interest is due on the total fee for each month or fraction of a month that payment
11. $
INTEREST
is made after the due date. The adjusted monthly interest rate is
12.
TOTAL AMOUNT DUE AND PAYABLE (add lines 9, 10, and 11)
12.
$
EMAIL ADDRESS
I hereby certify that this return, including any accompanying schedules and statements, has been
examined by me and is, to the best of my knowledge and belief, a true, correct, and complete return.
SIGNATURE
PRINT NAME AND TITLE
TELEPHONE
DATE
(
)
Make check or money order payable to State Board of Equalization.
Always write your account number on your check or money order. Make a copy of this document for your records.
CLEAR
PRINT
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