State Form 42936 - Petition To The Indiana Board Of Tax Review For Review Of Assessment Page 3
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3SECTION IV: SIGNATURES
PETITIONER, TAXPAYER, OR DULY AUTHORIZED EMPLOYEE OR CORPORATE OFFICER OF THE TAXPAYER
I certify that my entries in SECTION I and SECTION III are accurate to the best of my knowledge and belief. I also understand that by
appealing my assessment, my assessment may increase, may decrease, or may remain the same.
Date signed (month, day, year)
Signature of petitioner, taxpayer or duly authorized officer
Title (please print or type)
Printed or typed name of petitioner, taxpayer or duly authorized officer
TAX REPRESENTATIVE
I certify that the entries in SECTION I and SECTION III are accurate to the best of my knowledge and belief. I certify that
I have viewed this property, the property record card, and State Form 20916 / Form 115, and that I have the authority to file this
appeal on behalf of the taxpayer. I certify that I have made all necessary disclosures to my client, pursuant to 52 IAC 1-2-2.
Date signed (month, day, year)
Signature of tax representative
Printed or typed name of tax representative
ATTORNEY REPRESENTATIVE
I certify that the entries in SECTION I and SECTION III are accurate to the best of my knowledge and belief.
Date signed (month, day, year)
Signature of attorney representative
Attorney number
Printed or typed name of attorney representative
SECTION V: CERTIFICATE OF SERVICE
I affirm under the penalties of perjury that a copy of this petition has been served on the following via First Class United States Mail, postage,
prepaid, this ____________ day of ________________, 20_____.
If this petition is filed by the county assessor
Taxpayer:
Taxpayer:
County Assessor:
County Assessor:
Signature
FORM 131 CHECKLIST
I have attached the Notification of Final Assessment Determination (State Form 20916 / Form 115).
I have attached a copy of the written notice filed with the county or township assessor to initiate this appeal. If I filed the
Form 130 (State Form 21513) or Form 130-Short (State Form 53958) to initiate this appeal, a copy has been attached.
I have filed a separate petition for each appeal year.
I have filed a separate petition for each parcel unless permission was given to file a single petition for multiple parcels.
If I am appealing both real property and personal property assessments, I have filed separate petitions for each type of property.
I have checked the type of property under appeal (real or personal) on page 1.
I have identified any other pending appeals for this parcel on page 1.
If there are other related parcels currently under appeal, a listing of these parcels has been attached.
I have reviewed Section II, selected a small claims option, and initialed.
I have explained in detail the basis for my belief that the assessment is incorrect (Section III).
If this petition is being filed by an authorized tax representative, a duly executed power of attorney and a Tax Representative
Disclosure Statement are attached.
I have completed Section I, Section II, Section III, Section IV, Section V, and signed this petition.
I have served a copy of this petition on the other party (Section V).
Information regarding appeal procedures and hearing practice is available on the IBTR website located at
Form 131, page 3
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