Dor Form 82061-B - Property Tax Form - Mines (Other Than Copper) - 2014 Page 19
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19VERIFICATION
CONFIDENTIAL
Company Name___________________________________
For the Year Ended December 31, 2012
State of_________________________________
County of________________________________
I,_______________________________________, being duly sworn, upon my oath say that
I am the_________________________________ of the_______________________________________
and that the information contained in the report is complete, true and correct, according
to the best of my knowledge, information and belief.
Further, the taxpayer waives its rights to confidentiality under A.R.S. Section 42-2001
through 42-2004 with respect to pages A4, A16, A17and A18 of this report, and consents to
the disclosure of such information to county assessors and their personnel by the Arizona
Departmemnt of Revenue in order to assure that all property is properly assessed and to help
protect against double assessments.
____________________________________
Signature
Subscribed in my presence and sworn to before me, a Notary Public, in and for said
County and State, by___________________________________________ on this the_______ day
of__________________, a.d. 20____.
My commission expires______________________, ________.
In witness Whereof, I have hereunto set my seal of office.
DOR Form 82061-B (Rev. 11-12)
PAGE A19 OF A19
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