BOE-567-K

Source: https://www.boe.ca.gov/proptaxes/pdf/sample-boe567k.pdf

This page watermarked sample only. Contact Assessor BOE-567-K (P1) REV. 09 (07-25) for actual form. OFFICIAL REQUIREMENT 20 This statement is not a public document. The information A report submitted on this form is required of you by section ANNUAL GEOTHERMAL contained herein will be held secret by the assessor (code441(a) of the Revenue and Taxation Code (Code). The section 451); it can be disclosed only to the district attorney, statement must be completed according to the instructions OPERATING EXPENSE DATA grand jury, and other agencies specifi ed in Code section and fi led with the Assessor on or before April 1, 20 . 408. Attached schedules are considered to be part of the Failure to file it on time will compel the Assessor’s Office to statement. estimate the value of your property from other information in its possession and add a penalty of 10 percent as required by Code section 463. CAREFULLY READ AND FOLLOW THE ACCOMPANYING INSTRUCTIONS.

1. NAME AND MAILING ADDRESS (make necessary corrections to the printed name and mailing address): 2. DESCRIPTION OF THE PROPERTY (a separate report must be filed for each property): Field Name Lease Name 3. PARCEL NUMBER: Tax Rate Area Form

2. Well data: Type: Dry steam Water Hot rock ASSESSOR’S USE ONLY NUMBER AVERAGE WELL DEPTH ONLY

3. Producing wells fl owing

4. Producing wells pumping Actual

5. Shut-in wells capable of producing

6. Idle wells incapable of producing a. With equipment b. Without equipment for

7. Injection wells

8. Water supply: Fresh Salt

9. Disposal wells

FIELD OPERATING EXPENSES:* ASSESSOR’S USE ONLY 12. Labor (including employee benefi ts)13. Materials and supplies (expensed itemsSAMPLEonly) 14. Well maintenance (pulling, bailing, etc.) 15. Contract work and rentals16. Insurance Assessor 17. Utilities 18. Injection 19. Transportation 20. Waste water disposal 21. Waste disposal (sludge) 22. Overhead (direct-field or district) (see instructions) 23. Other (fully explain on attached sheet)24. Contact 25. 26. 27. 28. 29. TOTAL FIELD OPERATING EXPENSES

• Do not include depletion, depreciation, amortization, interest on loans, franchise and property taxes, state and federal income taxes, or royalty payments.

  THIS REPORT SUBJECT TO AUDIT

This page watermarked sample only. Contact Assessor for BOE-567-K (P2) REV. 09 (07-25) actual form.

CAPITAL EXPENDITURES (during the calendar year being reported): ASSESSOR’S USE ONLY

30. New wells

    DATE FLOW CAPABILITY

WELL NUMBER DATE BEGUN COMPLETED TYPE* DEPTH (Kg x 106/HR) COST

*P = Producing, I = Injection, D = Disposal TOTAL NEW WELL COST

31. Remedial well work

    WELL NUMBER DATE COMPLETED DEPTH COST Form

    TOTAL REMEDIAL WELL WORK COST

32. Abandonments ONLY

    DATE

WELL NUMBER DEPTH COST SALVAGE VALUE ABANDONED Actual for

TOTAL ABANDONMENT COST (net)

33. Surface investment

    Pads — Roads SAMPLE Facilities Assessor TOTAL SURFACE INVESTMENT

34. Other (fully explain on attached sheet)

35. TOTAL CAPITAL EXPENDITURES

    DECLARATION BY ASSESSEE

    Note: The following declaration must be completed and signed. If you do not do so, it may result in penalties.

I declare under penalty of perjury under the laws of the State of California that I have examined this expense data statement, and that the foregoing and all information herein, including any accompanying statements or materials, is true, correct, and complete to the best of the taxpayer's knowledge and belief, and includes allproperty and thoseContactexpenses required to be reported which is owned, claimed, possessed, controlled, or managed by the person named as the assessee in this statement at 12:01 a.m. on January 1, 20 .

SIGNATURE OF ASSESSEE OR AUTHORIZED AGENT* DATE
OWNERSHIP
TYPE (3)
NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed) TITLE

Proprietorship

Partnership NAME OF LEGAL ENTITY (other than DBA) (typed or printed) FEDERAL EMPLOYER ID NUMBER Corporation PREPARER’S NAME AND ADDRESS (typed or printed) TELEPHONE NUMBER TITLE Other

EMAIL ADDRESS

*Agent: See page P4 for Declaration by Assessee instructions.

This page watermarked sample only. Contact BOE-567-K (P3) REV. 09 (07-25) Assessor for actual form.

INSTRUCTIONS FOR COMPLETING THE ANNUAL GEOTHERMAL
OPERATING EXPENSE DATA REPORT

Line numbers listed in these instructions refer to identical line numbers printed on the form. At top of form, fill in the year of the lien
date for which this expense report is made.

LINE 1. DATE, NAME, MAILING ADDRESS AND PHONE NUMBER
a. NAME OF OPERATOR (person or corporation)
If the name is preprinted, check the spelling and correct any errors. In the case of an individual, enter the last name
first, then the first name and middle initial. Partnerships must enter at least two names, showing the last name, first
name, and middle initial for each partner. Corporation names should be complete so they will not be confused with
fictitious or DBA (Doing Business As) names.

b. DBA OR FICTITIOUS NAME
Enter the DBA name under which you are operating in this county below the name of the sole owner, partnership or
corporation. c. MAILING ADDRESS Form
Enter the mailing address of the legal entity shown in line 1a. above. This may be either a street address or a post
office box number. It may differ from the actual location of the property. Include the city, state, and zip code.

d. PHONE NUMBER ONLY
Enter the phone number where we may contact you or your authorized representative for information regarding the
subject property. Actual
LINE 2. DESCRIPTION OF THE PROPERTY
Report each lease, parcel or “operating unit” on a separate report form. Operating unit refers to the accumulated
total of wells producing in concert to supply a designated energy generation system. Fill in field, lease name, and unit for number.

Conform to Division of Oil and Gas classification in regard to name of field, unit or lease.

LINE 3. PARCEL NUMBER
Fill in the parcel number and tax rate area number, if known. LINE 4. WELL DATA SAMPLE— Indicate type

LINES 5. Producing wells reported are those wells which actually contribute to normal unit production on a profitable basis. Indicate
and 6. number producing and average well depth for the zone. Assessor

LINE 7. Indicate number of shut in wells capable of production.

LINE 8. Indicate number of idle wells incapable of production (a) with equipment intact, (b) without equipment intact.

LINE 9. Indicate number of injection wells and average depth.

LINE 10. Indicate number of water supply wells and check one of the boxes to indicate whether they are fresh or salt water wells. Contact LINE 11. Indicate number of disposal wells and their average depth.

This page watermarked sample only. Contact BOE-567-K (P4) REV. 09 (07-25) Assessor for actual form.

LINES 12. FIELD OPERATING EXPENSE thru 29. Report direct field operating expenses only. Do not report capitalized items or royalty payments on these lines. Overhead expense applies to direct field overhead, district overhead, or any other direct overhead expenses relating to this lease or unit operation.

LINES 30. CAPITAL EXPENDITURES thru 35. Wells, remedial well work, abandonments and surface investment are those incurred during the calendar year being reported. Do not include items such as roads under new well cost, but report these separately on line 33.

Do not include depreciation, depletion, amortization, interest, federal and state income taxes, property taxes, royalty payments, and general office overhead.

DECLARATION BY ASSESSEE

The law requires that this expense data statement, regardless of where it is executed, shall be declared to be true under penalty of perjury under the laws of the State of California. The declaration must be signed by the assessee, a duly appointed fi duciary, or a person authorized to sign on behalf of the assessee. In the case of a corporation, the declaration must be signed by an offi cer or by an employee or agent who has been designated in writing by the board of directors, by name or by title, to sign the declaration on behalf of the corporation. In the case of a partnership, the declaration must be signed by a partner or an authorized employee or agent. In the case of a Limited Liability Company Form(LLC), the declaration must be signed by an LLC manager, or by a member where there is no manager, or by an employee or agent designated by the LLC manager or by the members to sign on behalf of the LLC.

When signed by an employee or agent, other than a member of the bar, a certified public accountant, a public accountant, an enrolled agent or a duly appointed fiduciary, the assessee’s written authorization of the employee or agent to sign the declaration on behalf of the assessee must ONLYbe fi led with the Assessor. The Assessor may at any time require a person who signs an expense data statement and who is required to have written authorization to provide proof of authorization.An expense data statement that is not signed and executed in accordance with the Actualforegoing instructions is not validly filed. The penalty imposed by section 463 of the Revenue and Taxation Code for failure to file is applicable to unsigned expense data statements. for SAMPLE Assessor Contact