BOE-100BR

Source: https://www.boe.ca.gov/proptaxes/pdf/sample-boe100br.pdf

THISTHIS PAGEPAGE WATERMARKEDWATERMARKED SAMPLESAMPLE ONLYONLY CONTACTCONTACT ASSESSORASSESSOR FORFOR ACTUALACTUAL FORMFORM

BOE-100-BR REV. 3 (2-17) STATE OF CALIFORNIA COUNTY ASSESSOR REFERRAL— BOARD OF EQUALIZATION LEGAL ENTITY INTEREST TRANSFER

INSTRUCTIONS: This form is to be completed by County Assessors and submitted to the State Board of Equalization (BOE) in order to notify BOE of a potential change in control or ownership under Revenue and Taxation Code section 64(c)(1) or 64(d) of a legal entity that owns an interest in California real property within their jurisdiction. The completed form should be sent to: California State Board of Equalization, County-Assessed Properties Division, P.O. Box 942879, Sacramento, CA 94279-0064; ATTN: Legal Entity Ownership Program. Note: BOE will send a written request to file form BOE-100-B, Statement of Change in Control and Ownership of Legal Entities, to obtain specific information on the transaction described below if a BOE-100-B was not previously filed.

COUNTY NAME DATE OF REFERRAL

COUNTY CONTACT TELEPHONE NUMBER ( ) NAME OF ACQUIRED ENTITY OR ENTITY THAT CHANGED OWNERSHIP UNDER 64(d) FORM ENTITY ID NUMBER TYPE OF ENTITY (check one)

CORPORATION PARTNERSHIP LIMITED LIABILITY COMPANY

NAME OF ACQUIRING ENTITY (if known) ENTITY ID NUMBER (if known)

DATE OF TRANSACTION (approximate) SOURCE OF INFORMATION (newspaper article, internet, property statement, PCOR, SEC form 10-K, merger agreement, etc.) Submit a copy of the document.

CIRCUMSTANCES OF TRANSACTION ONLY ACTUAL

IDENTIFY PROPERTY HELD BY THE ACQUIRED ENTITY LOCATED IN YOUR COUNTY; LIST SITUS - APN, STREET, CITY. INDICATE IF PROPERTY WAS PREVIOUSLY EXCLUDED UNDER SECTION 62(a)(2). PROVIDE DATE AND PARTIES TO TRANSFER. (You may attach a separate listing,FORif necessary.) SAMPLE

ENTITY CONTACT NAME (if known) TITLE

COMPANY TELEPHONE NUMBER ( ) MAILING ADDRESS (city, state, zip code) ASSESSOR Please note: The BOE-100-B, Statement of Change in Control and Ownership of Legal Entities, is due within 90 days from the date of request. Please allow several months for the BOE to respond to your referral.

BOE USE ONLY
BOE ANALYSIS INDICATES BOE-100-B FILING WAS:
Date Referral Received: _____________________ Received prior to referral Not Received prior to referral

IF FILING NOT RECEIVED

Entity Sent a BOE-100-B Request to File: _______________________________________________________ ID Number: __________________________

Mail Date of Request: _______________________ Due Date of Request: __________________ Mail Date of Second Request: ___________________

INFORMATION ON FILING

Date BOE-100-B Filed: ______________________ Name of Filer: _________________________________________________________________________CONTACT
Filing Indicates (check one) Change In Control (CIC) - 64(c) Change In Ownership (CIO) - 64(d) No CIC/CIO

Date of CIC/CIO: ___________________________ CIC/CIO Qualifies for an Exclusion: YES NO If YES, Statute: __________________

DATE COUNTY NOTIFIED COMMENTS: OF FINDINGS

THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION