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property information as of 12:01 A.M., January 1, 20

This page BOE-571-L (P1) REV. 27 (05-21) watermarked SAMPLE. BUSINESS property . STATEMENT FOR 2022. (Declaration of costs and other related property information as of 12:01 . , January 1, 2022). FILE RETURN BY APRIL 1, 2022. NAME AND MAILING ADDRESS. (Make necessary corrections to the printed name and mailing address). LOCATION OF THE BUSINESS property . STREET. CITY. RETURN THIS ORIGINAL FORM. COPIES WILL NOT BE ACCEPTED. FILE A SEPARATE STATEMENT FOR EACH LOCATION. PART I: GENERAL information . COMPLETE (a) THRU (g). a. Enter type of business: f. Enter name and telephone number of authorized person to contact at location of b.

g. During the period of January 1, 2021 through December 31, 2021: (1)Did any individual or legal entity (corporation, partnership, limited liability company, etc.) acquire a "controlling interest" (see instructions for definition) in this business entity? Yes No

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Transcription of property information as of 12:01 A.M., January 1, 20

1 This page BOE-571-L (P1) REV. 27 (05-21) watermarked SAMPLE. BUSINESS property . STATEMENT FOR 2022. (Declaration of costs and other related property information as of 12:01 . , January 1, 2022). FILE RETURN BY APRIL 1, 2022. NAME AND MAILING ADDRESS. (Make necessary corrections to the printed name and mailing address). LOCATION OF THE BUSINESS property . STREET. CITY. RETURN THIS ORIGINAL FORM. COPIES WILL NOT BE ACCEPTED. FILE A SEPARATE STATEMENT FOR EACH LOCATION. PART I: GENERAL information . COMPLETE (a) THRU (g). a. Enter type of business: f. Enter name and telephone number of authorized person to contact at location of b.

2 Enter local telephone number FAX number accounting records: Email Address g. During the period of January 1, 2021 through December 31, 2021: c. Do you own the land at this business location? Yes No (1) Did any individual or legal entity (corporation, partnership, limited liability company, If yes, is the name on your deed recorded etc.) acquire a "controlling interest" (see instructions for definition) in this business E. as shown on this statement? Yes No entity? Yes No d. When did you start business at this location? DATE: (2) If YES, did this business entity also own "real property " (see instructions for definition).

3 If your business name or location has changed from last year, enter the former name in California at the time of the acquisition? Yes No and/or location: (3) If YES to both questions (1) and (2), filer must submit form BOE-100-B, Statement of PL. e. Enter location of general ledger and all related accounting records (include zip code): Change in Control and Ownership of Legal Entities, to the State Board of Equalization. See instructions for filing requirements. PART II: DECLARATION OF property BELONGING TO YOU COST ASSESSOR'S USE ONLY. (attach schedule for any adjustment to cost) (omit cents). (see instructions). 1. Supplies M.

4 2. Equipment (From line 35). 3. Equipment out on lease, rent, or conditional sale to others (Attach Schedule). 4. Bldgs., Bldg. Impr., and/or Leasehold Impr., Land Impr., Land (From line 71). 5. Construction In Progress (Attach Schedule). SA. 6. Alternate Schedule A (See instructions). 7. 8. PART III: DECLARATION OF property BELONGING TO OTHERS IF NONE WRITE NONE . (SPECIFY TYPE BY CODE NUMBER). Year Year Description Cost to Annual Report conditional sales contracts that are not leases on Schedule A. of of and Lease or Purchase Rent 1. Leased equipment 4. Vending equipment t Acq. Mfr. Identification New 2. Lease-purchase option equipment 5.

5 Other businesses Number 3. Capitalized leased equipment 6. Government-owned property Tax Obligation: A. Lessor B. Lessee 9. Lessor's name t Mailing address 10. Lessor's name Mailing address OWNERSHIP TYPE (R) DECLARATION BY ASSESSEE. Proprietorship Note: The following declaration must be completed and signed. If you do not do so, it may result in penalties. Partnership I declare under penalty of perjury under the laws of the State of California that I have examined this property statement, including accompanying schedules, statements or other attachments, and to the best of my knowledge and belief it is true, correct, and complete and includes all Corporation property required to be reported which is owned, claimed, possessed, controlled, or managed by the person named as the assessee in this statement Other _____ at 12:01 on January 1, 2022.

6 BUSINESS SIGNATURE OF ASSESSEE OR AUTHORIZED AGENT* DATE. DESCRIPTION (R) t Retail NAME OF ASSESSEE OR AUTHORIZED AGENT* (typed or printed) TITLE. Wholesale Manufacturer NAME OF LEGAL ENTITY (other than DBA) (typed or printed) FEDERAL EMPLOYER ID NUMBER. Service/Professional PREPARER'S NAME AND ADDRESS (typed or printed) TELEPHONE NUMBER TITLE. ( ). *Agent: See page 7 for Declaration by Assessee instructions. THIS STATEMENT SUBJECT TO AUDIT. information PROVIDED ON A property STATEMENT MAY BE SHARED WITH THE CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION. BOE-571-L (P2) REV. 27 (05-21). SCHEDULE A COST DETAIL: EQUIPMENT (Do not include property reported in Part III.)

7 Include expensed equipment and fully depreciated items. Include sales or use tax (see instructions for important use tax information ), freight and installation costs. Attach schedules as needed. Lines 18, 32, 33, and 45 "Prior" Report detail by year(s) of acquisition on a separate schedule. L 1. 2. 3. 4. I Calendar MACHINERY AND EQUIPMENT FOR OFFICE FURNITURE OTHER EQUIPMENT Calendar TOOLS, MOLDS, N Year INDUSTRY, PROFESSION, OR TRADE (describe) Year DIES, JIGS. E of AND EQUIPMENT. (do not include licensed vehicles) of Acq. ASSESSOR'S ASSESSOR'S Acq. ASSESSOR'S. N. COST ASSESSOR'S USE ONLY COST COST COST. O USE ONLY USE ONLY USE ONLY.

8 11 2021 2021. 12 2020 2020. 13 2019 2019. 14 2018 2018. 15 2017 2017. 16 2016 2016. 17 2015 2015. 18 2014 Prior 19 2013 Total 5a. 20 2012. PERSONAL. Calendar Year COMPUTERS. 21 2011 of Acq. E. ASSESSOR'S. 22 2010 COST. USE ONLY. 23 2009 2021. 24. 25. 2008. 2007. PL 2020. 2019. 26 2006 2018. 27 2005 2017. M. 28 2004 2016. 29 2003 2015. 30 2002 2014. SA. 31 2001 2013. 32 2000 Prior 33 Prior Total 5b. 34 Total Calendar LOCAL AREA NETWORK (LAN). Year EQUIPMENT AND MAINFRAMES. of Add TOTALS on lines 19, 33, 34, 46 and any additional schedules. Acq. 35 ASSESSOR'S. ENTER HERE AND ON PART II, LINE 2 COST. USE ONLY. 36 ASSESSOR'S USE ONLY 2021.

9 CLASSIFICATION COL FULL VALUE BASE PERS. PROP. PERS. PROP. PERS. PROP. 37 FULL VALUE 2020. RCLND ADJUSTMENT FULL VALUE. Machinery 38 1 2019. & equipment Office furniture 39 2 2018. & equipment Tools, molds, 40 4 2017. dies & jigs 41 Personal Computers 5a 2016. 42 LAN and Mainframe 5b 2015. 43 2014. Other 44 3 2013. equipment Schedule B. 45 _ Prior Fixtures 46 TOTALS Total Thispage wate This page SAMPLE. BOE-571-L (P3) REV. 27 (05-21). watermarked SCHEDULE B COST DETAIL: BUILDINGS, BUILDING IMPROVEMENTS, AND/OR LEASEHOLD IMPROVEMENTS, LAND IMPROVEMENTS, SAMPLE. LAND AND LAND DEVELOPMENT. Attach schedules as needed. Line 69 "Prior" Report detail by year(s) of acquisition on a separate schedule.

10 BUILDINGS, BUILDING IMPROVEMENTS, AND/OR 3. 4. L. I LEASEHOLD IMPROVEMENTS LAND LAND AND LAND. N Calendar 1. 2. IMPROVEMENTS DEVELOPMENT. E Year of STRUCTURE ITEMS ONLY FIXTURES ONLY ( , blacktop, curbs, fences) ( , fill, grading). N Acq. (see instructions) (see instructions). O. ASSESSOR'S ASSESSOR'S ASSESSOR'S ASSESSOR'S. COST COST COST COST. USE ONLY USE ONLY USE ONLY USE ONLY. 47 2021. 48 2020. 49 2019. 50 2018. 51 2017. 52 2016. 53 2015. 54 2014. 55 2013. 56 2012. E. 57 2011. 58 2010 PL. 59 2009. 60 2008. 61 2007. 62 2006. M. 63 2005. 64 2004. 65 2003. SA. 66 2002. 67 2001. 68 2000. 69 Prior 70 Total 71 Add TOTALS on line 70 and any additional schedules.


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