BOE-572-A

Source: https://www.boe.ca.gov/proptaxes/pdf/sample-boe572a.pdf

This page watermarked sample only. Contact Assessor for actual form.

BOE-572-A (P1) REV. 03 (07-25)

INSURANCE COMPANY STATEMENT OF TRANSFER File this report with the Assessor of the county where the real property is located.

NAME AND MAILING ADDRESS (Make necessary corrections to the printed name and mailing address)

This is a written request made pursuant to section 480.7 of the Revenue and Taxation Code. This report must be completed in detail by the taxpayer and filed with the Assessor within 45 days from the date of the subject transfer of real property. Failure to file on time will result in a penalty of $1,000 in addition to any other penalty prescribed by law.If no transfers of the type described have occurred, you do not have to file at this time. If a transfer occursFormin the future, you are required to file this report within 45 days of the transfer. If a Change in Ownership Statement or Preliminary Change of Ownership Report has been filed for this transaction, attach a copy. PROPERTY INFORMATION

1. DATE OF TRANSFER OF REAL PROPERTY 2. AMOUNT OF CONSIDERATION 3. TYPE OF CONSIDERATION (MONEY, GOODS, ETC.) ONLY

2. LOCATION AND DESCRIPTION OF PROPERTY Actual 5. TRANSFERRED FROM 6. TRANSFERRED TO ACCOUNT ID ACCOUNT NAME ACCOUNT ID ACCOUNT NAME for

3. TYPE OF TRANSFER. CHECK AND COMPLETE THE APPROPRIATE TYPE. a. PURCHASE/SALE

   b. LEASE/PURCHASE: LEASE PAYMENT $ LEASE END BUYOUT $

   c. JOINT VENTURE: PARTNERS BEGINNINGSAMPLE% CHANGE % OWNED BEGINNING END

   d. INTERNAL REALLOCATION: FROM TO Assessor

4. CONTACT INFORMATION NAME OF PERSON TO CONTACT DAYTIME TELEPHONE NUMBER ( )

COMPANY NAME OF PERSON TO CONTACT EMAIL ADDRESS

ADDRESS CITY STATE ZIP CODE

CERTIFICATION Contact Note: This statement must be signed. Failure to do so could result in penalties. I certify (or declare) under penalty of perjury under the laws of the State of California that I have examined this return, 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 covers all property required to be reported by the person named in this statement. If prepared by a duly authorized person other than the taxpayer, the declaration is based on all the information of which the preparer has knowledge.

SIGNATURE OF OWNER, PARTNER, OFFICER, OR LEGAL AGENT DATE t PRINT NAME OF AUTHORIZED SIGNER TITLE

COMPANY NAME EMAIL ADDRESS

THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION

This page watermarked sample only. Contact Assessor for actual form.

BOE-572-A (P2) REV. 03 (07-25)

OFFICIAL REQUIREMENT

This is a written request made pursuant to Revenue and Taxation Code section 480.7. This report must be completed in detail by the taxpayer and filed with the Assessor within 45 days from the date of the subject transfer of real property. Failure to file it on time will result in a penalty of $1,000 in addition to any other penalty prescribed by law. This report is not a public document. The information contained herein will be held secret by the Assessor (Revenue and Taxation Code section 451); it can only be disclosed to the district attorney, grand jury, and other agencies specified in Revenue and Taxation Code section 408. Attached schedules are considered to be part of the report.

INSTRUCTIONS

The purpose of this statement is to identify and report to the county assessor the transfer of real property that was/is held by an insurance company in a separate account (i.e., separate accounts established either under California Insurance Code Section 10506 or under corresponding insurance laws of the company’s state of domicile). References to real property in the following instructions pertain to that real property held in separate accounts. Form1. Date of transfer: Enter the date the real property was transferred.

2. Cost: Enter the amount of consideration.3. Type: Enter the medium of the transaction–money, goods, trade,ONLYetc.

3. Location/Description of Property: Enter the exact location (street address, city, and Zip Code) of the real property and describe (assessor’s parcel number or complete legal description). Actual

4. Transferred from: Enter the separate account identifying number and account name, or the identification of the third party seller, to which the real property was transferred from. for

5. Transferred to: Enter the separate account identifying number and account name, or the identification of the third party buyer, to which the real property was transferred to.

6. Type of transfer (Check the appropriate box): a. Purchase/sale. The transfer was because of the purchase or sale of real property to or from the separate account. b. Lease Purchase. TheSAMPLEtransfer was because of the lease purchase of real property to or from the separate account. Indicate the amount of the lease payment (i.e., $10,000/Month), and lease end buy out. c. Joint Venture. The transfer was because of the actions of joint venture. Enter the percentage interest of the joint venture allocated to the separateAssessoraccount at the time of the joint venture’s acquisition of the real property and any changes in the percentage interest of the joint venture allocated (or internally reallocated) to the separate account as a result of the transfer. Enter the percent interest in the real property owned by the joint venture before and after the transfer. d. Internal Reallocation. The transfer was because of an internal reallocation. Indicate the from/to accounts involved in the internal reallocation.

7. Contact Information: Enter the name, daytime telephone number, company name, mailing address, and Email address of the person to contact if questions about the real property or this statement should arise. Contact ATTACHMENTS: In lieu of filling out Questions 1 through 8, you may attach a listing. The listing must clearly provide all the requested information and must be listed in the same order as shown on the form.

SIGNATURE: This property statement must be signed by an officer or by an employee or agent whom the board of directors has designated in writing, by name or by title, to sign the statement on behalf of the corporation. The board of directors may appoint a person or persons to designate such employee or agent. A record of the written authorization of the appointment and designation must be retained by the assessee for a period of six years from the date of its execution.