BOE-540-S

Source: https://www.boe.ca.gov/proptaxes/pdf/sample-boe540s.pdf

This page watermarked sample only. Contact Assessor for actual form. BOE-540-S (P1) REV. 07 (07-25) OFFICIAL REQUIREMENT 20_____ This statement is not a public document. The information A report submitted on this form is required of you MUTUAL OR PRIVATE WATER contained herein will be held secret by the Assessorby section 441(a) of the Revenue and Taxation Code (Code section 451); it can be disclosed only to the district (Code). The statement must be completed according COMPANY attorney, grand jury, and other agencies specified in Code to the instructions and filed with the Assessor on or PROPERTY STATEMENT section 408. Attached schedules are considered to be part of the before April 1, 20____ . Failure to file it on time will statement. compel the Assessor’s Office to estimate the value of your property from other information in its possession and add a penalty of 10 percent as required by Code 2. LOCATION OF EACH WATER SYSTEM: section 463. (a separate statement must be filed for each system located (Make necessary corrections to the printed name and mailing address.) in this county. See Instructions.)

1. NAME AND MAILING ADDRESS

   3. LOCAL PHONE NUMBER ( )
   E-Mail Address (optional)

2. TYPE OF SERVICE: Domestic Irrigation 5.OWNERSHIP: Proprietorship Partnership Corporation Other

3. YEAR STARTED SERVICE FINANCIAL DATA FOR YEAR ENDING

BALANCE AT ADDITIONS RETIREMENTS OTHER BALANCE TANGIBLE PLANT ASSESSOR’S BEGINNING DURING DURING ADJUSTMENTS AT END (omit cents) USE ONLY OF YEAR YEAR YEAR OF YEAR Form Land $ $ $ $ $ Water Rights Buildings Other Improvements ONLY Lakes and Springs Other Source of Supply Wells Actual Pump Equipment Purification Equipment ReservoirsTanks for Mains Services Meters Hydrants Office Furniture and Equipment Mobile Equipment Not Licensed by DMVTools, Shop and Other Equipment SAMPLE Total Plant (sum of above items) Accrued Depreciation Total Plant Less Accrued Depreciation Assessor Construction Work in Progress Materials and Supplies

REMARKS:

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 Contactpenalty of perjury under the laws of the State of California that I have examined this property 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 all property 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

NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed) TITLE

NAME OF LEGAL ENTITY (other than DBA) (typed or printed) FEDERAL EMPLOYER ID NUMBER

PREPARER’S NAME AND ADDRESS (typed or printed) TELEPHONE NUMBER TITLE ( )

*Agent: see back for Declaration by Assessee instructions. THIS STATEMENT SUBJECT TO AUDIT

This page watermarked sample only. Contact Assessor for actual form. BOE-540-S (P2) REV. 07 (07-25) STATISTICAL DATA AS OF DECEMBER 31, 20

YEAR ORIGINAL SIZE OR CA- LENGTH OR ASSESSOR’S NUMBER TYPE LOCATION INSTALLED COST PACITY DEPTH USE ONLY

Buildings $

Other improvements

Lakes and springs

Other source of supply

Wells

Pump equipment

Purification equipment

Reservoirs Form Tanks

Mains — pipe lines — canals & ditches ONLY Services

Meters Actual

Hydrants Office furniture and equipment for

Average number of customers during year Total amount of water delivered during year Does company own water rights in this county in addition to the water system? Yes No If yes, attach a listing and description of the water rights.

PROPERTY OWNED BY OTHERS Did you hold merchandise or other personalSAMPLEproperty on consignment at 12:01 a.m. on January 1? Yes No If yes, list the name and address of the consignor, quantity, description and total amount to be remitted to consignor on a separate schedule and attach to this statement. Did you hold equipment belonging to others on a loan, rental or lease basis at 12:01 a.m. on January 1? Yes No If yes, list the name and address of the owner or lessor, description, year constructed, cost if purchased, and rental on a separate schedule and attach to this statement. Are any other individuals, partnerships, corporations, or joint ventures doing business on your premises? Yes No If yes, list the name and address of the owner and Assessor briefly describe the nature of the business on a separate schedule and attach to this statement.

INSTRUCTIONS The Assessor may provide forms to allocate by code area the property described in this statement. All property (wells, pump houses, pumping plants, reservoirs, tanks, pipe lines, services, etc.) located on land owned by the assessee must be identified by the Assessor’s Parcel Number of the land upon which located. If additional space is needed, attach a schedule that lists the parcel numbers. The exact location of personal property (office furniture and equipment, other equipment, unlicensed equipment, construction work in progress, materials and supplies) on the land owned by the assessee, must be identified by the Assessor’s Parcel Number of the land upon which located. If additional space is needed, attach a schedule that lists the parcel numbers. Each system which is not connected to any other system by pipe lines or canals is considered to be a unit for appraisal purposes. If costs are available, complete the schedule of Financial Data on the front of the property statement, along with the statistical data on the reverse side. If cost data isContactnot available and it is not feasible to develop cost, a description of the physical property, with date of construction or installation and original costs, should be reported in the schedule headed, Statistical Data as of December 31, 20 .

DECLARATION BY ASSESSEE The law requires that this property 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 fiduciary, or a person authorized to sign on behalf of the assessee. In the case of a corporation, the declaration must be signed by an officer 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 (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 be filed with the Assessor. The Assessor may at any time require a person who signs a property statement and who is required to have written authorization to provide proof of authorization. A property statement that is not signed and executed in accordance with the foregoing 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 property statements.