Drill Rig Declaration Schedule (Page 2 of 3) in pdf

16 DPT-AS

State of Colorado

Form

OIL AND GAS ROTARY DRILLING RIG

DS 656 02-16

DECLARATION SCHEDULE

Assessment Date

Due Date

(CONFIDENTIAL DATA)

January 1,

April 15,

2016

COUNTY

RETURN TO COUNTY ASSESSOR

B.A. CODE

T.A. CODE

SCHEDULE NUMBER

If you are not the current business owner please list the name and

address of the new owner below.

Date Sold _________________

DRILLING RIG NUMBER:

A. NAME AND ADDRESS

(INDICATE ANY CHANGES OR CORRECTIONS)

DO NOT USE – FOR ASSESSOR ONLY

CONDITION

 Poor/Stacked

 Fair

 Good

 V.Gd.

RECEIVED

LEGAL DESCRIPTION OF THE LOCATION OF THE SKID-MOUNTED

COMPLETED

ROTARY DRILLING RIG AS OF JANUARY 1, 2016 OR THE DATE

LATE FILING PENALTY APPLIED:

 YES

 NO

THE RIG FIRST ENTERED A COLORADO COUNTY:

B. LOCATION ON FILING DATE: LEGAL DESCRIPTION OF

THE LOCATION OF THE SKID-MOUNTED ROTARY DRILLING

RIG ON THIS FILING DATE:

County: ________________________ Section: _________________

County: ________________________ Section: ________________

Twnshp: __________ Range: ___________ Qrtr.Sect: ___________

Twnshp: __________ Range: ___________ Qrtr.Sect: __________

Note: Drilling Log must be attached to this declaration.

C. COUNTY OF ORIGIN: ____________________

Names of other counties where the rig

Number of days the rig

Number of Days in Colorado: ________________

operated in 2015 (including current county)

was in each county

Number of Days in County:

________________

Depth Capacity of Rig:

________________

Number of Drill Collars:

________________

Linear Feet of Drill Pipe:

________________

Condition of Rig:  Poor/Stacked  Fair  Good  Very Good

Is Drilling Rig licensed with Colorado SMM tags or decals? If so, please

attach copies

 YES

 NO

D. NEW HIGH-TECHNOLOGY RIGS

Date in Service

Max Depth Rating

Original Cost

 Over-top Drive Coil Rig (without wheels)

 Flex Rig (adjustable platform and drilling depths – without wheels)

E. LEASED, LOANED, OR RENTED EQUIPMENT:

Owner’s/Lessor’s

Description of Equipment:

Lease

Name

Address

Type

Model #

Serial #

Lease #

Term

Cost

Total Rent

F. DECLARATION

THIS RETURN IS SUBJECT TO AUDIT

“I declare, under penalty of perjury in the second degree, that this schedule, together with any accompanying exhibits or

statements, has been examined by me and to the best of my knowledge, information, and belief sets forth a full and complete

list of all taxable personal property owned by me, or in my possession, or under my control, located in this county, Colorado,

on the assessment date of this year; that such property has been reasonably described and its value fairly represented; and that

no attempt has been made to mislead the assessor as to its age, quality, quantity, or value.” § 39-5-107(2), C.R.S.

PROPERTY OWNER’S FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)/SOCIAL SECURITY NUMBER (SSN) ________________________

NAME OF OWNER _____________________________________________________________________________________________________

PRINT NAME OF PERSON SIGNING ______________________________________ PHONE NUMBER _____________________________

E-MAIL ADDRESS ___________________________________________________________ FAX NUMBER ___________________________

SIGNATURE OF OWNER OR AGENT __________________________________________ DATE __________________________________

Check here if new agent. If new agent, submit a letter of authorization when filing this form.



PLEASE COMPLETE, SIGN AND RETURN THIS FORM TO THE ASSESSOR ON OR BEFORE APRIL 15, 2016.

MAKE A COPY FOR YOUR RECORDS.

Drill Rig Declaration Schedule Page 2

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