Dor Form 82061-A - Property Tax Form - Cooper Mines - 2014 Page 25
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25CONFIDENTIAL
Company Name:_____________________________
For the Year Ended December 31, 2012
VERIFICATION
State of_________________________________
County of________________________________
I,_______________________________________, being duly sworn, upon my oath say that
I am the_________________________________ of the_______________________________________
and that the information contained in this 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. Sections 42-2002
through 42-2006 with respect to pages A4, A20, A21, A22 and A23 of this report, and consents to
the disclosure of such information to County Assessors and their personnel by the Arizona
Department 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.
_____________________________________
Notary Public
DOR Form 82061-A (Rev. 11-12)
PAGE A25 OF A25
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