Form 130 - Petition To The Property Tax Assessment Board Of Appeals For Review Of Assessment Page 3

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SECTION III: SIGNATURES
PETITIONER, TAXPAYER, OR DULY AUTHORIZED EMPLOYEE OR CORPORATE OFFICER OF THE TAXPAYER
I certify that my entries in SECTION I and SECTION II 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
Printed or typed name of petitioner, taxpayer or duly authorized officer
Title (please print or type)
TAX REPRESENTATIVE
I certify that the entries in SECTION I and SECTION II are accurate to the best of my knowledge and belief. I certify that I have
viewed this property, the property record card, and Form 11 or Form 113, 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 50 IAC 15-5-5.
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 II are accurate to the best of my knowledge and belief.
Date signed (month, day, year)
Signature of attorney representative
Printed or typed name of attorney representative
Attorney number
FORM 130 CHECKLIST
I have reviewed Form 11 RA, Form 11 CI, or Form 113
I have reviewed the property record card
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) at the top of page 1
I have completed Section I, Section II, and Section III of this petition
I have given SPECIFIC REASONS for the requested change in value in Section II of this petition
If this petition is being filed by an authorized tax representative, a duly executed power of attorney and Tax Representative
Disclosure Statement is attached
I have signed this petition
I understand that I must submit the original and one copy of this form to the County Assessor
If there are other related parcels currently under appeal, a listing of these parcels has been attached
FOR COUNTY ASSESSOR'S USE ONLY
RECEIPT
1. Date Assessment Notice was sent to taxpayer
2. Date Petition for Review was filed by petitioner (within 45 days of notice)
Signature of Assessor
3. Petition for review timely filed?
Date of signature (month, day, year)
Yes
No
If the answer to # 3 above is "No", the County Assessor shall notify the petitioner that the petition was not timely filed.
Form 130, page 3

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