Vehicle Assessment Appeal Form For Condition Of Vehicle Or For High Mileage Adjustment

Page 2

Vehicle Assessment Appeal Form

For Condition of Vehicle or For High Mileage Adjustment

Required Vehicle Information:

Make __________

Model ___________

Year

__________

Vehicle Identification Number (VIN) ______________________________

Odometer Reading (no tenths)

______________________________

If condition appeal, describe in detail the physical condition of the vehicle as of

January 1 of the applicable tax year: ___________________________________

_________________________________________________________________

[Attach additional pages if necessary, along with any supporting documentation]

AFFIDAVIT

Subject to the penalty proscribed by Virginia Code §58.1-11, I certify that the information

contained on this form is complete and accurate.

Given under my hand this _____ day of _________________, 20_____.

Signature _________________________________________________

Print Name ________________________________________________

Social Security Number _______-________-________

Daytime Telephone Number _______-________-________

E-Mail Address ____________________________________________

(Rev. 9-2010)

_____________________________

Submitting this form, along with the requested documentation, does not relieve the requirement to pay the tax by the

indicated due date. If near the due date, pay the amount due and any adjustments will be refunded as appropriate.

Privacy Act Notice: Disclosure of your Social Security Number, if any, on this form is mandatory. The Fairfax County

Department of Tax Administration is requesting this number in accordance with the authority provided by Virginia

Code Section 58.1-3017 and 42 U.S.C. Section 405. Social Security Numbers are used as a means of identification

for the filing, retrieval and processing of local tax appeal applications. Those numbers are also used where necessary

to facilitate tax collection and to provide tax refunds to taxpayers. Social Security Account Numbers are regarded as

confidential tax information, and except as otherwise provided by law, those numbers will not be disclosed for any

other purpose. If you do not disclose a Social Security Number, you may encounter problems in the processing of

your tax appeal application and refunds, if applicable.

Vehicle Assessment Appeal Form For Condition Of Vehicle Or For High Mileage Adjustment - 2010 Page 2