The Central American river turtle (Dermatemys mawii) is a large Critically Endangered freshwater turtle historically found in the coastal lowlands of southern Mexico, northern Guatemala, and Belize. Due to years of intense harvesting for its meat, D. mawii has been virtually eliminated from much of its former range in southern Mexico, while its status in Guatemala remains unclear. During April and May 2010, we conducted a countrywide survey in Belize to assess the current conservation status of D. mawii in what is believed to be its last stronghold. We surveyed approximately 30 localities from deep southern to extreme northern Belize, including 17 areas previously surveyed during the early 1980s and 1990s. Results indicate D. mawii is heavily depleted in most of Belize, but healthy populations remain in a few remote areas (including multiple, previously unsurveyed localities in southern Belize), especially those receiving some level of protection. While this mirrors the trend observed in previous surveys, the current findings are of particular concern because the number of localities where turtles were observed and the number of turtles observed at these localities were both much reduced compared to earlier surveys. Large turtles (reproductive adults) continue to be targeted during harvests, significantly reducing the most demographically important segment of the population. Further, interviews with fishermen and hunters indicate that laws and regulations enacted for the protection of D. mawii are largely ignored by locals, as broad-scale enforcement is difficult or impossible to achieve. In this paper, we discuss survey results in the context of previous investigations, describe levels and sources of exploitation, and provide conservation recommendations.