Lat 12 - Personal Property Report - Oil And Gas Property (Page 2 of 3) in pdf

Lat 12 - Personal Property Report - Oil And Gas Property Page 2

DESCRIPTION OF ALL PROPERTY OWNED IN WARD – SUBMIT SEPARATE REPORT FOR EACH WARD

DESCRIPTION OF WELLS AND/OR

ACTUAL

WELL

LEASE

WELL

ACTIVE LOWER

FAIR MARKET

ASSESSED

WELL

TYPE

SURFACE EQUIP BY LEASE

AGE*

SERIAL

PERF.

VALUE

NUMBER

CONSIGNED GOODS, LEASE, LOANED, OR RENTED EQUIPMENT, FURNITURE, ETC.

NAME AND ADDRESS

PROPERTY DESCRIPTION

AGE

MONTHLY

PRESENT DAY

FAIR MARKET

RENTAL

SELLING PRICE

VALUE

TOTAL FAIR MARKET VALUE

ASSESSED VALUE

PENALTIES FOR FAILURE TO FILE THIS FORM INCLUDE WAIVER OF RIGHTS

NEED ASSISTANCE?

AFTER YOU REVIEW THE ENCLOSED

TO APPEAL YOUR ASSESSMENT AND MAY INCLUDE A MONETARY

TAX FORM AND YOU FEEL YOU NEED ASSISTANCE PLEASE

PENALTY (RS 47:1992 & 2330)

CALL YOUR ASSESSOR LISTED ABOVE AT

. THANK YOU

SIGNATURE AND VERIFICATION

“I declare under the penalties for filing false reports (R.S. 14:125; up to 500.00 fine or imprisonment for one year or both, plus additional penalties defined in Act

2330B of the 1989 Regular Section) that this return has been examined by me and to the best of my knowledge and belief is a true, correct and complete return.” “If

the return is prepared by someone other than the taxpayer, authorized officer, or partner, this form must be notarized.”

SIGNATURE OF TAXPAYER

DATE

SIGNATURE OF PREPARER

DATE

PRINTED/TYPED NAME OF TAXPAYER

PRINTED/TYPED NAME OF PREPARER

Actual age of surface equipment should be reported separately from well serial number, if known or

available.

12/28/2015

REVISION DATE: