BOE-517-TC (S1F) REV. 15 (12-12)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
DECLARATION OF COSTS AND OTHER RELATED PROPERTY INFORMATION
AS OF 12:01 A.M., JANUARY 1, 2013
This statement must be completed, signed, and filed with the State-Assessed Properties Division, Board of Equalization,
P.O. Box 942879, Sacramento, California 94279-0061, by March 1, 2013. Omit cents; round to the nearest dollar.
NAME, STREET, CITY, STATE and ZIP CODE
This request is made in accordance with section 826 of the Revenue
and Taxation Code. This property statement must be completed
according to the instructions and filed with the Board of Equalization
(BOE) on or before March 1, 2013. If you do not file this statement,
you may be subject to the penalty provided in section 830 of the
Revenue and Taxation Code. Attached schedules are considered to
be part of the statement. THIS STATEMENT IS SUBJECT TO AUDIT.
MAKE NECESSARY CORRECTIONS TO ADDRESS LABEL
Indicate if above is a change of name and/or address.
NAME AND ADDRESS OF PERSON TO WHOM CORRESPONDENCE
DATE TO BE
THIS STATEMENT SHALL CONSIST OF:
REGARDING AUDIT SHOULD BE ADDRESSED:
(1) Financial Schedules A through D
(2) Schedules of Leased Equipment
MAILING ADDRESS (including zip code)
(3) Summary Control
(4) Schedule of Intangible Information
(5) Tangible Property List
(6) Statement of Land Changes, BOE-551
(7) Statement of Authorization, BOE-892
LOCATION OF ACCOUNTING RECORDS (street, city, state, and zip code)
(8) Other information
(see instructions on reverse)
a. 2012 Annual Report to CPUC
b. 2012 Annual Report to FCC
c. 2012 SEC Form 10K —2 copies
NAME OF AUTHORIZED REPRESENTATIVE (if applicable)
d. 2012 Shareholders Report—3 copies
ADDRESS (street, city, state, and zip code)
e. Franchise Payments for Cable TV
f. Payments to Local Governments in CA
DAYTIME TELEPHONE NUMBER
g. Other information as requested
* BOE-892, Statement of Authorization, must be filed annually.
List business activities: ________________________________________________________________________________________________________
Has your company taken a FASB write-down to reflect a reduction in the value of your fixed assets?
If yes, enter the date the write-down was booked __________________________________________________
(4) ENTITY TYPE:
Change in ownership prior 12 months?
I certify (or declare) under penalty of perjury under the laws of the State of California that I have examined this Property Statement, including accompanying schedules
and statements, and to the best of my knowledge and belief it is true, correct, and complete and covers all property required to be reported which is owned, claimed,
possessed, controlled, or managed by the person named in the statement at 12:01 a.m. on January 1, 2013. If prepared by a person other than the taxpayer, this
declaration is based on all information of which preparer has knowledge.
FULL LEGAL NAME OF BUSINESS
FOR OFFICIAL USE ONLY
PRINTED NAME OF SIGNATORY
SIGNATURE OF OWNER, PARTNER, OR CORPORATE OFFICER
SIGNATURE OF AUTHORIZED REPRESENTATIVE
INFORMATION PROVIDED ON A PROPERTY STATEMENT MAY BE SHARED WITH OTHER STATE BOARD OF EQUALIZATION DEPARTMENTS